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This report was prepared by Dr. Joan Almost, RN, PhD, Associate Professor, School of Nursing, Queen’s University, and Scholar in Residence, Canadian Nurses Association.

Suggested citation Almost, J. (2021). Regulated nursing in Canada: The landscape in 2021. Canadian Nurses Association.

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ISBN 978-1-55119-452-3 Table of Contents

Foreword...... v

Introduction...... 1

Nursing in Canada: Statistics...... 3

Nursing in Canada: An overview...... 7 LICENSED PRACTICAL NURSES...... 10 REGISTERED PSYCHIATRIC NURSES...... 11 REGISTERED NURSES...... 12 NURSE PRACTITIONERS...... 13 ADVANCED PRACTICE NURSING...... 16 Clinical Nurse Specialists...... 17 General Comparison of Clinical Nurse Specialist Roles and Nurse Practitioner Roles...... 19 Nurse Midwives...... 20 Specialty practice ...... 22

Nursing Structures and Roles...... 25 REGULATORS ...... 27 Licensed Practical Nurse Regulators...... 29 Registered Psychiatric Nurse Regulators...... 29 Registered Nurse Regulators...... 30 Nurse Practitioner Regulators...... 31 PROFESSIONAL ASSOCIATIONS...... 31 Licensed Practical Nurses’ Professional Associations...... 32 Registered Psychiatric Nurses’ Professional Associations...... 33 Registered Nurses’ Professional Associations...... 33 Nurse Practitioners Professional Associations...... 35 EDUCATIONAL ASSOCIATIONS...... 36 Licensed Practical Nurses Education Associations...... 37 Registered Nurses and Nurse Practitioners Education Associations...... 37 NURSING UNIONS...... 39

Regulated Nursing in Canada: The Landscape in 2021 i Nursing Education...... 41 LICENSED PRACTICAL NURSE EDUCATION...... 42 REGISTERED PSYCHIATRIC NURSE EDUCATION...... 44 REGISTERED NURSE EDUCATION...... 46 NURSE PRACTITIONER EDUCATION...... 48 GRADUATE EDUCATION...... 50 DOCTORAL EDUCATION...... 50

Scope of Practice...... 53 OUTER LIMITS OF SCOPE OF PRACTICE...... 54 Legislation and Profession Regulation...... 54 Regulation ...... 56 Professional Standards and Guidelines...... 56 ACTUAL SCOPE OF PRACTICE...... 57 Environment or Setting Context...... 57 Individual Nurse...... 57 The Client, Patient, Community and/or Population...... 59 LICENSED PRACTICAL NURSES...... 60 Requisite Skills and Abilities ...... 60 Entry-Level Competencies...... 61 Registration Requirements ...... 62 Standards of Practice...... 63 REGISTERED PSYCHIATRIC NURSES...... 64 Requisite Skills and Abilities...... 64 Entry-Level Competencies...... 64 Registration Requirements...... 65 Standards of Practice...... 66 REGISTERED NURSES...... 67 Requisite Skills and Abilities...... 67 Entry-Level Competencies ...... 67 Registration Requirements...... 68 Standards of Practice...... 69 Registered Nurse Prescribing...... 71 British Columbia...... 71 Alberta ...... 72 Saskatchewan ...... 72 ii Manitoba...... 73 Nova Scotia...... 74 Ontario ...... 74 Quebec ...... 74 NURSE PRACTITIONERS...... 74 Entry-level competencies ...... 74 Registration Requirements...... 76 Standards of Practice...... 77

Unregulated Care Providers...... 81

Physician Assistants...... 85 NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS...... 87

Conclusion and Next Steps...... 89

References...... 91

Appendix A. Overview of Number of Institutions Offering Entry-Level Nursing Education Programs and Programs Available...... 111 Appendix B. Licensed Practical Nurses...... 115 Appendix C. Registered Psychiatric Nurses ...... 127 Appendix D. Registered Nurses...... 132 Appendix E. Nurse Practitioners ...... 144

Regulated Nursing in Canada: The Landscape in 2021 iii

Foreword

In June 2018, the Canadian Nurses Association (CNA) started a new chapter in its history with an overwhelming vote by its members to open membership beyond registered nurses and nurse practitioners to include licensed practical nurses1 and registered psychiatric nurses. It then fell to the organization to dismantle 110 years of structures and language focused only on registered nurses. The work on building new governance and membership structures, as well as a rebranding of CNA to embrace new categories of members, began immediately and is still underway.

It became clear during consultations with nurses leading up to the 2018 vote that not only were many nurses unclear about the different roles, mandates, and titles of their professional, union, and regulatory bodies, there was also confusion and sometimes suspicion and outright resentment about scopes of practice and the ways they do or do not overlap across the four regulated designations. This served to remind us that nursing is not a homogenous group, and that we have probably paid less attention than we should have to understanding the internal dynamics of nursing — our intraprofessional education, practice and collaboration. As a result, CNA led development of an intraprofessional collaboration framework that guided a position statement intended to bring some clarity to this charged issue (CNA, 2020c).

More recently, work done for the CNA with nurses across the country showed consensus that “intraprofessional collaboration is pivotal to high quality patient care and healthy work environments” (Lankshear & Limoges, 2019). However, although there are many examples of different types of nurses working well together, it’s undeniable that longstanding tensions and rivalry sometimes get in the way of delivering the best care. That suggested a deeper understanding of the education, roles, scopes, and regulation of the four designations of nursing could lead to strategies to improve the deployment of all types of nurses to maximize their effectiveness in delivering the best patient care possible.

1 In the interest of simplicity, we use licensed practical nurse throughout this document, while acknowledging that in Ontario, the category is regulated with the title registered practical nurse.

Regulated Nursing in Canada: The Landscape in 2021 v Thus, it became clear, leading into the Year of the Nurse and the Midwife in 2020, that a comprehensive narrative, clearly outlining the similarities, differences, and practices of the regulated designations could help clarify the nursing story, reduce confusion and serve as a critical resource for the profession and others who need to understand nurses and nursing.

As it happened, in the spring of 2018, Dr. Joan Almost, an Associate Professor in the School of Nursing at Queen’s University, and then Associate Director, Graduate Nursing Programs, approached me to express her interest in contributing to professional nursing and policy work during her then forthcoming sabbatical. Having known Joan for more than two decades, I knew her to be a rigorous thinker, superb writer, and a courageous asker of tough questions. And Joan is tenacious about getting projects done well. I knew she would be perfect for creating a much-needed document that would not only describe the landscape of nursing in Canada, but also inform future work on intraprofessional practice. We engaged Joan’s talents as our Scholar in Residence, and this paper, Regulated Nursing in Canada: The Landscape in 2021, is the culmination of her work.

The paper speaks methodically and extensively to the history, structures, regulatory requirements, roles, education, and scopes of practice of the four regulated designations of nurses in Canada, as well as touching on advanced practice nursing, specialty nursing practice and nurse midwives. The paper also describes the roles of physicians’ assistants and unregulated care providers who work with nurses and whose roles overlap with nursing. The extensive menu of tables provides rapid access to detailed information about each designation of nurses and all the support structures around them at provincial, territorial and federal levels. We will endeavour to sustain Joan’s work as a living document so that the resources are kept current for the policy leaders, scientists, employers and students across the country who we know will be frequent users of the data therein.

Since 2018, Joan has become more than a visitor at CNA – she has become a valued team member, presenting updates on this work at board meetings and annual general meetings, and

vi participating in many of our policy and other events. Joan’s rigour and academic stamina for the long-haul work, packaged with her dry, fun sense of humour, have been important contributions to our team and to me personally. We are so pleased to publish and share her great gift to CNA and nursing in Canada as we launch a new year. I know you all will join me in thanking Joan for her two years of very hard work to bring this project to life.

Michael J. Villeneuve, RN, M.Sc., FAAN Chief Executive Officer Canadian Nurses Association

February 1, 2021

Introduction

As Canada’s population changes, so too do its health-care needs and expectations. Policymakers have grappled for many years with determining the best use of a workforce consisting of a variety of health-care professionals to achieve the Quadruple Aim of improving the experience for both patients and those providing care, the value of care provided, and the health of the population (Bodenheimer & Sinsky, 2014). This includes aligning the composition, competencies, and accountabilities of regulated nurses, the largest group of regulated health professionals in Canada, consisting of four designations: licensed practical nurses (registered practical nurses in Ontario), registered psychiatric nurses, registered nurses, and nurse practitioners. Registered psychiatric nurses are regulated in British Columbia, Alberta, Saskatchewan, Manitoba, and the Yukon Territory, and the other three categories are regulated in and practice in all 13 provinces and territories.

Nursing is a profession built on collaborative relationships that may be interprofessional, involving a variety of health care professionals, or intraprofessional, involving nurses from among the four regulated designations. While much research and discussion has focused on interprofessional practice over the past several decades, there is a growing recognition and motivation among nurses to strengthen intraprofessional practice. However, historical power structures and a lack of role clarity among the different designations have been entrenched within the profession over many decades. This has resulted in significant challenges for licensed practical nurses, registered psychiatric nurses, registered nurses, and nurse practitioners to come together to advance nursing around a shared vision. To move forward, meaningful change requires a questioning of the traditional hierarchies and a clearer understanding of the four regulated designations of nurses.

The objective of this pan-Canadian synthesis is to describe the current state of nursing in Canada to provide clarity and a fulsome understanding of all regulated nurses in Canada. Specifically, the report will provide an overview of regulated nurses in Canada, the structure and organization of nursing (regulatory bodies, professional associations, educational associations, and unions), the educational preparation of nurses, their scope of practice, and how their work differs from that of unregulated health care providers.

Regulated Nursing in Canada: The Landscape in 2021 1

Nursing in Canada: Statistics

In 2019, the number of regulated nurses with active licenses rose to 439,975 (Table 1), an increase of 1.9% from 2018. However, the employed nursing workforce decreased by 0.5% (Canadian Nurses Association, 2020a). Over the past five years, growth in nurse practitioners has exceeded that of the other three categories. This trend continued in 2019 as the nurse practitioner supply grew by 8.1% compared with 3.6% for licensed practical nurses, 1.1% for registered nurses, and 0.4% for registered psychiatric nurses (Canadian Institute for Health Information, 2020a). However, licensed practical nurses had the greatest growth by number with an increase of 4,497 nurses (Canadian Nurses Association, 2020a).

Table 1. Numbers of regulated nursing personnel by designation in Canada

2008 2013 2019 Licensed Practical Nurses 81,099 106,525 127,097 Registered Psychiatric Nurses 5,241 5,621 6,050 Registered Nurses 277,677 292,374 300,669 Nurse Practitioners 1,669 3,655 6,159 Total 365,686 408,175 439,975

Source: Canadian Institute for Health Information. (2020a).

In 2019, across all designations, most regulated nurses were aged 35 to 54 (Canadian Institute for Health Information, 2020a). As a group, the nursing workforce employed in direct care is becoming younger. Since 2010, the proportion of nurses under the age of 35 has increased by 7.5%, and the proportion of nurses 55 years and older have decreased by 3.2%. The licensed practical nurse workforce has the greatest proportion in the early career stage (35.9%) with the registered psychiatric nurses’ workforce having the greatest percentage in the late career stage (25.8%) (Canadian Institute for Health Information, 2020a; Canadian Nurses Association, 2020a).

The propotion of male regulated nurses has grown by 15.4% over the last 5 years, whereas the supply of female regulated nurses has only grown by 3.9% over the same period. Registered psychiatric nurses have the highest proportion of male nurses (19%) compared with female nurses (81%) (Canadian Institute for Health Information, 2020a).

Regulated Nursing in Canada: The Landscape in 2021 3 The majority of regulated nurses were employed in the profession at the time of registration, with 58% of the workforce employed full time, 32% employed part-time, and 10% employed on a casual basis (Canadian Institute for Health Information, 2020a). As shown in Figure 1, in both 2010 and 2019, the majority of licensed practical nurses, registered psychiatric nurses, and registered nurses reported working in hospitals with minimal change between the two data points. During this time, less licensed practical nurses reported working in long-term care, while more registered psychiatric nurses reported working in community health settings. In 2010, the majority of nurse practitioners reported working in community health setting. However, in 2019, there was a rise in the number working in other settings, including business/industry/occupational health office, private nursing agency/private duty, self-employed, educational institution, association/government, correctional agency and other places of work.

Figure 1. Place of work by regulated nurse designations: 2010 and 2019

0 50 100

Licensed Practical Nurses

Registered Psychiatric Nurses

Registered Nurses

Nurse Practitioners

ospital Community ealth Long-term care Other

Source: Canadian Institute for Health Information, 2020b

4 Regulated Nursing in Canada: The Landscape in 2021 5

Nursing in Canada: An overview

While there are many differences between each of the regulated designations, there are also many similarities (Council for Practical Nurse Regulators, 2013a; Registered Psychiatric Nurses Regulators of Canada, 2015a). In general, each designation requires:

1. Provincial/territorial legislation governing its practice, 2. Completion of a nursing education program approved by regulatory bodies, 3. Demonstration of entry-level competencies developed by the regulatory bodies, 4. Demonstration of requisite skills and abilities (cognitive, behavioural, communication, interpersonal, physical skills, sensory perceptual and environmental) identified by the regulatory body to safely engage in practice, 5. Demonstration of evidence of good character expected of the profession, 6. Submission of a satisfactory criminal record review, 7. Passing an approved entry-to-practice examination, 8. Registration with the appropriate regulatory body to practise, 9. Demonstration of fitness to practise and meeting standards of practice which promote, guide, and direct professional nursing practice, 10. Meeting the regulatory body’s language requirements, 11. Holding professional liability protection, and 12. Maintaining competence through continuous learning and experience.

When examining each of these requirements more closely, the differences between the designations and across Canada become more apparent (Table 2). For example, each designation is registered to practice in all provinces and territories with the exception of registered psychiatric nurses who are able to register with the regulatory bodies in only the western provinces and the Yukon. Entry-level education ranges from a diploma to master’s degree and only registered psychiatric nurses write the same registration examination in each of their jurisdictions. A few provinces require the passing of a jurisprudence

Regulated Nursing in Canada: The Landscape in 2021 7 examination, while others require the successful completion of a jurisprudence module. This varies, however, by jurisdiction and designation. Ontario and Nova Scotia are the only two provinces requiring jurisprudence examinations for all designations of nurses regulated in their provinces. British Columbia and Quebec require the successful completion of a practical examination (i.e., Objective Structured Clinical Examination or OSCE) for nurse practitioners. The following section provides an overview of each of the regulated nursing designations, advanced practice nursing, and specialty practice followed by more detail in the subsequent sections.

8 Table 2. Comparison of Four Regulated Designations by Registration, Entry-level Education, and Registration Examinations

Licensed Practical Nurses Registered Psychiatric Registered Nurses Nurse Practitioners Nurses Registration All 13 provinces and Manitoba, Saskatchewan, All 13 provinces and All 13 provinces and territories territories Alberta, British Columbia, territories Yukon Entry-level Diploma Baccalaureate or diploma Baccalaureate program, Master’s education except in Quebec which has both baccalaureate and diploma entry-level education Registration Currently, Canadian Registered Psychiatric National Council Recognized registration exams, except Quebec: examination Practical Nurse Registration Nurses of Canada Licensure Examination for Examination, except in Examination administered RNs (NCLEX-RN), except Primary Health Care/Family Quebec which requires by Manitoba, in Quebec which requires • Canadian Nurse Practitioner Exam in family (all ages) Ordre des infirmières et Saskatchewan, Alberta examination from • American Nurses Credentialing Center exam in family care infirmiers auxiliaires du and British Columbia. Ordre des infirmières et • American Academy of Nurse Practitioners exam in family Québec exam infirmiers du Québec care In 2022, Ontario and British Jurisprudence exam Pediatrics Columbia will use the or module required in Regulatory Exam - Practical six provinces (British • Pediatric Nursing Certification Board nurse practitioner Nurse (REx-PN); Eight Columbia, Alberta, exam jurisdictions will use a Ontario, New Brunswick, • American Nurses Credentialing Centre exam in pediatrics computer-adaptive exam Nova Scotia, Prince (2005-2014) Edward Island) (Yardstick Assessment Adult Strategies) (Yukon, Alberta, Saskatchewan, Manitoba, • American Nurses Credentialing Centre exam in adult care New Brunswick, Nova (2005-2014) Scotia, Prince Edward Island, • American Nurses Credentialing Centre exam in adult- Newfoundland and Labrador. gerontology primary care • American Academy of Nurse Practitioners exam in adult- Jurisprudence exam gerontology primary care or module required in • American Academy of Nurse Practitioners exam in adult five provinces (Alberta, care Manitoba, Ontario, New Brunswick and Nova Scotia) Quebec has separate exams for nurse practitioners specializing in neonatology, adult care, pediatric care, primary care, and mental health.

British Columbia and Quebec also require a practical examination (i.e., Objective Structured Clinical Examination or OSCE). Jurisprudence examination required in two provinces (Ontario, Nova Scotia). Course on prescribing controlled drugs and substances required in 4 jurisdictions (Northwest Territories and Nunavut, Nova Scotia, Prince Edward Island, Newfoundland and Labrador)

Regulated Nursing in Canada: The Landscape in 2021 9 LICENSED PRACTICAL NURSES In Canada, it was the shortage of registered nurses prior to the start of World War II that led to the recognition that nursing assistants needed formal education beyond on-the-job training (Mussallem, 1965; Russell, 1970). As a result, the practical nursing designation was established to provide support for registered nurses and substitute for them under certain circumstances (Pringle et al., 2004). In 1946, Manitoba was the first province that required practical nurses to register with a provincial/territorial regulatory body as a condition of practice. By 1988 most provinces and territories had regulation in place, with Nunavut being the last to pass legislation in 2011.

Over time, a variety of titles have been used to refer to practical nurses, including nursing aides, nursing assistants, nursing auxiliaries, and attendants. For example, in Ontario in 1947, the Nurses’ Act was amended to provide for the title Certified Nursing Assistant. In 1963, this title was changed to Registered Nursing Assistant. In 1993, Registered Nursing Assistants were allowed to use the title nurse and to adopt the designation of Registered Practical Nurse with the proclamation of the Regulated Health Professions Act (WeRPN, n.d.). The title practical nurse was used in both Manitoba and British Columbia when the educational programs were established in these provinces. Today, the title licensed practical nurse is used in all provinces and territories except for Ontario where the title is registered practical nurse based on legislation.

Today, licensed practical nurses make up 29% of the regulated nursing workforce (Canadian Institute for Health Information, 2020a) and are regulated in all provinces and territories. Entry-level registration criteria include graduating with a diploma from an approved education program and passing the Canadian Practical Nurse Registration Examination or professional examination in Quebec. Education programs are available in all provinces and the Northwest Territories, but not in the Yukon or Nunavut. Licenced practical nurses work autonomously within their own level of competence and seek guidance from other health-care professionals when aspects of the required care are beyond their individual competence (Council for Practical Nurse Regulators, 2013a). They assess, plan, implement and evaluate care for clients. They commonly work in a variety of practice settings, including but not limited to, hospitals, long-term care homes, public health units, community nursing agencies, private practices, clinics, physicians’ offices, industry, schools, adult daycare centres, private homes, community health centres, childcare centres, and children’s camps (Canadian Institute for Health Information, 2011). The practice of practical nursing occurs within the domains of direct practice, education, administration, and research.

10 REGISTERED PSYCHIATRIC NURSES Registered psychiatric nurses were first regulated in Saskatchewan in 1948 in part as a response to the nurse shortage resulting from World War II. British Columbia followed in 1951, then Alberta in 1955 and Manitoba in 1960. Regulation in the Yukon occurred in 1990 under their Health Professions Act resulting in Yukon becoming the first territory to register psychiatric nurses (Registered Psychiatric Nurses Regulators of Canada, 2015a). The emergence of the registered psychiatric nurse profession was marked by an interplay between social, economic and political factors in Canada that influenced the emergence of two models with a division at the Manitoba-Ontario border. West of this border, registered psychiatric nursing was a distinct profession from general nursing, while east of it, psychiatric nursing was a specialty within general or registered nursing (Registered Psychiatric Nurses Regulators of Canada, 2015b). This divide continues to exist today, though additional provinces are having discussions about the possibility of regulating registered psychiatric nurses.

Today, registered psychiatric nurses form the largest single group of professional mental health service providers in Western Canada (Registered Psychiatric Nurses Regulators of Canada, 2015a). However, they only make up about 1.4% of the Canadian nursing workforce. They work both autonomously and in collaboration with other health care team members to coordinate health care and provide client-centred services to individuals, families, groups, and communities (Registered Psychiatric Nurses Regulators of Canada, 2015a). They focus on mental and developmental health, mental illness, and addictions, while integrating physical health and utilizing bio-psycho-social and spiritual models for a holistic approach to care (Registered Psychiatric Nurses Regulators of Canada, 2014a). Registered psychiatric nurses practice in a variety of settings across the sectors of health, social and family services, justice, and education. They work in psychiatric facilities, hospitals, crisis services, addictions agencies, community mental health programs for children, adolescents, adults, and seniors, correctional facilities and programs, long term care facilities, and schools. They hold roles as staff nurses, psychiatric emergency nurses, mental health consultants, behavioral specialists, clinical specialists, managers or supervisors, chief executive officers, executive directors, educators, faculty, and researchers (Canadian Institute for Health Information, 2019; Registered Psychiatric Nurses Regulators of Canada, 2014a). The practice of psychiatric nursing occurs within the domains of direct practice, education, administration, and research (Registered Psychiatric Nurses Regulators of Canada, 2014a).

Entry-level registration criteria include graduating with a diploma or baccalaureate degree from one of the eight approved psychiatric nursing education programs in Canada and passing the Registered Psychiatric Nurses

Regulated Nursing in Canada: The Landscape in 2021 11 of Canada Examination (British Columbia College of Nursing Professionals, n.d.; Registered Psychiatric Nurses Regulators of Canada, 2015a). Currently the provinces of British Columbia, Alberta, Saskatchewan and Manitoba regulate and educate psychiatric nurses. The Yukon Territory also regulates registered psychiatric nurses but does not offer an entry-level education program (Registered Psychiatric Nurses Regulators of Canada, 2019a). In the provinces and territories that do not regulate registered psychiatric nurses, they often work in non-regulated nursing-related roles and are often prevented from applying the full scope of their knowledge and skills in the delivery of health care (Registered Psychiatric Nurses Regulators of Canada, 2015a).

REGISTERED NURSES Long before European settlement in Canada, Indigenous healers and midwives occupied important caregiving roles in their communities (Benoit & Carroll, 2005) with extensive knowledge of medicinal plants to treat ailments (Wytenbroek & Vandenberg, 2017). However, the history of the registered nurse in Canada often is traced to the 1600s with the arrival of Jeanne Mance in Quebec (Villeneuve, 2017). Although Mance was not a nun, she worked with Catholic nursing sisters who built a vast network of nurse-run hospitals, beginning in 1637 in Quebec City. By 1947, they operated at least 146 hospitals across Canada (Paul, 2005). Later, Florence Nightingale’s British nursing apprenticeship education model helped to solidify nursing as a respectable occupation for women. Before this model, hospital care was carried out by a variety of paid and unpaid, skilled and unskilled caregivers (McPherson, 2005). As hospital and scientific medicine advanced in the late 1800s, hospital care became focused on treatment and therapy (McPherson, 2005) and hospitals introduced trained nurses to elevate their status. In 1874, St. Catharines General and Marine Hospital in Ontario established the first hospital training school for nurses in Canada (Gibbon & Mathewson, 1947). The first registered nursing legislation in Canada was passed in Nova Scotia in 1910 and allowed for voluntary registration. The first registration act was passed in Manitoba in 1913, and by 1967 all provinces had some form of legislation for registered nurses (Villeneuve, 2017) with the Yukon, Northwest Territories and Nunavut passing legislation between 1973 and 1999.

Today, registered nurses make up 68% of the regulated nursing workforce (Canadian Institute for Health Information, 2020a). They work autonomously and in collaboration with others to enable individuals, families, groups, communities, and populations to achieve optimal levels of health. At all stages of life, in situations of health, illness, injury and disability, registered nurses deliver direct health-care services, coordinate care, and support clients in managing their own health. The majority of registered nurses continue to

12 work in hospitals, but they also work in a wide variety of settings, including residential care facilities, community health centres, independent practices (self-employed), faith communities, industry, mental health facilities, clinics, schools, colleges and universities, clients’ homes, the streets, correctional facilities, research institutes, professional nursing and health-care organizations and government agencies and departments (Canadian Nurses Association, 2015). Registered nurses practice in the domains of clinical practice, education, research, administration and policy.

Registered nurses are regulated in all provinces and territories. Entry-level registration criteria include graduating with a bachelor’s degree in nursing from an approved education program and passing the National Council Licensure Examination for RNs (NCLEX-RN) in all provinces, except in Quebec, where a diploma from an approved education program is accepted and passing the entry-to-practice professional exam from the Ordre des infirmières et infirmiers du Québec is required. Entry-level educations programs are available in all provinces and Nunavut with no programs currently available in the Yukon or Northwest Territories.

NURSE PRACTITIONERS In the 1890s, nurses and nurse midwives with expanded roles were introduced in northern and remote communities of Canada to ease ongoing physician shortages and lack of medical services. This role was the beginning of advanced practice nursing (Kaasalainen et al., 2010) and led to the emergence of the primary health care nurse practitioner (Canadian Nurses Association, 2008; MacLeod et al., 2004). During the mid 1960’s and 1970’s, new socio- political forces further influenced the development and implementation of the nurse practitioner role in primary care settings (also known as expanded role or family practice nurse at the time) (Allen 1999; Glass et al. 1974; King 1974). Initiatives to utilize these roles continued until the 1980s when major cuts in health-care spending took place and the focus shifted towards increasing the number of physicians. The lack of legislation to support the role, lack of remuneration mechanisms, little public awareness, perceived oversupply of physicians in urban areas, weak support from policy makers and other health professionals, and, ultimately, the absence of support from the medical community created major tensions surrounding the role implementation (Canadian Nurses Association, 2008). As a result, the role failed to be established further and in the mid 1980’s most educational programs were terminated with the exception of preparation of registered nurses working in remote areas (Canadian Nurses Association, 2008; DiCenso & Bryant-Lukosius, 2010a).

Regulated Nursing in Canada: The Landscape in 2021 13 However, in the late 1980s a blended Clinical Nurse Specialist/Nurse Practitioner role was first introduced in Ontario in tertiary-level neonatal intensive care units to help offset cutbacks in pediatric residents (Hunsberger et al., 1992; Pringle, 2007). The addition of Clinical Nurse Specialist to the title was done to emphasize the nonclinical advanced practice role dimensions, including education, research, and leadership (DiCenso, 2008; Hunsberger et al., 1992). Nurse practitioners in these roles were soon introduced into other specialty areas within hospitals (Pringle, 2007). In the 1990s, advanced practice nurses in these roles were renamed acute care nurse practitioners, then eventually changed to nurse practitioners.

From the mid-1990’s to the early 2000’s there was a renewed emphasis on primary health care and increased interest again in the primary health care nurse practitioner role (Donald et al., 2010b). This resurgence saw the creation or amendment of legislation with the first nursing legislation including nurse practitioners’ legislated authority, scope of practice, and regulation passed in British Columbia and Ontario in 1997. In 2005, the federal government provided funding for the Canadian Nurse Practitioner Initiative, led by the Canadian Nurses Association, to develop a framework for the integration and sustainability of the nurse practitioner role (Canadian Nurse Practitioner Initiative, 2006b). Educational programs grew, and regulatory frameworks were established to guide the registration, standards, and core competencies for nurse practitioner practice (Canadian Association of Schools of Nursing, 2012). Since completion of the Canadian Nurse Practitioner Initiative, there has been an explosion of the types and number of models of care that include nurse practitioners. For example, the first nurse practitioner-led clinic model was opened in Ontario in 2008 (Delvin, Braithwaite, & Plazas, 2018).

Over the past decade, the supply of nurse practitioners in Canada has more than tripled, from 1,669 in 2008 to 6,159 in 2019 (Canadian Institute for Health Information, 2020a). However, nurse practitioners still make up only about 1.4% of the Canadian nursing workforce. Ontario was one of the first provinces to recognize the nurse practitioner role, and today more than half of Canada’s nurse practitioners work in Ontario (n=3,451) with small numbers in most other provinces (Canadian Institute for Health Information, 2020a). Nurse practitioners are graduate degree-prepared registered nurses who practise autonomously and independently as advanced practice nurses. Advanced practice nursing is an umbrella term for nurses who integrate graduate nursing educational preparation with in-depth, specialized clinical nursing knowledge and expertise (Canadian Nurses Association, 2019a). This area of practice will be discussed in more detail in the next section.

Nurse practitioners integrate their knowledge of advanced practice and theory, health management, health promotion, disease and injury prevention,

14 and other relevant biomedical and psychosocial theories to provide comprehensive health services. They work with diverse client populations in a variety of contexts and practice settings. They provide comprehensive health assessments, diagnose and manage health/illness conditions, order and interpret screening and diagnostic tests, communicate diagnosis and test results to patients and other health-care professionals, recommend or prescribe treatment—including pharmaceuticals, medical devices and other therapies, manage acute and chronic illness within a holistic model of care, and perform specific procedures within their expanded legislated scope of practice (Canadian Nurses Association, 2016a; Nurse Practitioner Association of Canada, 2018). In addition to direct care responsibilities, aspects of their role also include education, consultation, leadership, and research (Canadian Nurse Practitioner Initiative, 2006a).

Nurse practitioners are currently regulated and practising in all provinces and territories. During the early years of nurse practitioner registration, various titles were used to describe nurse practitioners, such as registered nurses providing extended services in Alberta (Canadian Institute for Health Information, 2010). Today, registration exams support a population-based classification as nurse practitioners either write an adult, pediatric, or family/all ages exam (primary health care) with jurisdictions using terms such as ‘specialty’ ‘category’ or ‘stream’ (Spence et al., 2015). Some jurisdictions also register nurse practitioners in neonatology, either as a distinct stream or as part of the pediatric/child stream. Neonatal/neonatology nurse practitioners complete a post-master’s diploma in the provinces where the role is recognized (Kilpatrick et al., 2010). Québec also registers nurse practitioners in a mental health specialty (Ordre des infirmières et infirmiers du Québec, 2019a).

Based on titles, practice settings and populations, nurse practitioners have been generally categorized as primary health care or acute care nurse practitioners (DiCenso et al., 2010). Approximately 75% of nurse practitioners are primary health care nurse practitioners registered in the family/all-ages, primary care/all ages, or primary health care/all ages stream (also referred to as category or specialty in different jurisdictions) (Spence et al., 2015). They are specialists in primary health care, who provide accessible, comprehensive and effective care for clients across the lifespan, including newborns, children, adolescents, adults, pregnant and postpartum women, and older adults in a generalized or a specialty practice setting. The focus of their practice includes health promotion, preventive care, diagnosis and treatment of acute common illnesses and injuries, rehabilitation and management of stable chronic diseases. They typically work in settings such as community health setting, family physician offices, primary care networks, and long-term care (Donald et al., 2010a; Little & Reichert, 2018).

Regulated Nursing in Canada: The Landscape in 2021 15 Acute care nurse practitioners are registered in the adult, pediatrics/child or neonatal/neonatology stream (DiCenso & Bryant-Lukosius, 2010b; Kilpatrick et al., 2010). Nurse practitioners registered in the adult stream of practice normally provide care for individuals over the age of 18 years, in either a generalized adult practice where they see adults with a variety of medical conditions, or adults in a generalized or specialty practice setting, normally a hospital (College and Association of Registered Nurses of Alberta, 2017; College of Registered Nurses and Nurse Practitioners of Newfoundland and Labrador, 2019). Nurse practitioners registered in the pediatric stream of practice normally provide care for individuals under the age of 18 in either a generalized practice where they see individuals with a variety of medical conditions, or individuals in a generalized or specialty practice setting (College and Association of Registered Nurses of Alberta, 2017; College of Registered Nurses and Nurse Practitioners of Newfoundland and Labrador, 2019). In some instances, pediatric nurse practitioners may provide care to young adults whose developmental age may closely approximate that of a child or adolescent rather than an adult, or a young adult who has been receiving care from the nurse practitioner for a chronic disease since childhood. Nurse practitioners registered in the neonate or neonatology stream normally work in neonatal intensive care units with high risk infants (College and Association of Registered Nurses of Alberta, 2017; College of Registered Nurses and Nurse Practitioners of Newfoundland and Labrador, 2019).

Other terms commonly used when describing nursing roles or branches of nursing are advanced practice nursing and specialty practice. Each of these will be described in the following section.

ADVANCED PRACTICE NURSING In Canada, the roots of advanced practice nursing can be traced to the efforts of outpost nurses who worked in isolated areas such as the Northwest Territories, Labrador, and Newfoundland in the early 1890s, with the roles becoming more formalized starting in the 1960s (Kaasalainen et al., 2010). Today, advanced practice nursing is an umbrella term for nurses who integrate graduate nursing educational preparation with in-depth, specialized clinical nursing knowledge and expertise (Canadian Nurses Association, 2019a). Nurses working in these roles engage in direct clinical care and build on their clinical expertise in a specialty area by integrating research, education, leadership, consultation, collaboration, and a health systems approach (Canadian Nurses Association, 2019a). In contrast, advanced nursing practice reflects the integration and application of a broad range of theoretical and evidence-based knowledge that occurs as part of graduate nursing education. Advanced nursing practice encompasses all the domains of nursing practice,

16 the entire field of nursing and does not necessarily refer only to direct clinical care. For example, nurse educators, policymakers, researchers, managers, and administrators with graduate education may demonstrate advanced nursing practice in their roles. However, they would not be considered an advanced practice nurse because they do not engage in direct clinical care (Canadian Nurses Association, 2019a).

Several other terms, including expert, expanded and extended practice, are also used and can create confusion about the language and nature of advanced practice. In fact, the terms expanded or extended have historically been incorporated into legislation governing nurse practitioner practice in several provinces and territories with the meaning varying from one jurisdiction to the next. Extended or expanded roles normally refer to nursing practice that extends beyond the usual or regulated scope of nursing practice which may or may not include graduate nursing educational preparation. Expert practice can take place at any level of nursing practice and by any regulated nurse as nursing practice is often characterized along a continuum of novice to expert (MacDonald et al., 2005).

While there has been tremendous progress, the full potential of advanced practice nursing roles in Canada has yet to be realized. In a federal government advisory panel report, Unleashing Innovation: Excellent Health Care for Canada (2015), Naylor and colleagues frequently mentioned that advanced practice nursing roles are underused, despite clear evidence of their benefits to the health system and Canadians. The two advanced practice nursing roles recognized most commonly in Canada are the nurse practitioner and clinical nurse specialist (Canadian Nurses Association, 2019a). Nationally and internationally, nurse midwives, are also considered advanced practice nursing roles even though they are not required to have graduate education (MacDonald et al., 2005). An overview of nurse practitioners was provided previously. The following section will provide an overview of the clinical nurse specialist with a general comparison of the clinical nurse specialist role and the nurse practitioner role, followed by an overview of the nurse midwife.

Clinical Nurse Specialists A clinical nurse specialist is a registered nurse with graduate nursing education and expertise in a clinical speciality. Across Canada, the legislated scope of practice for the clinical nurse specialist is the same as that of the registered nurse. The exception is in Quebec, where the “clinical nurse specialist in infection prevention and control” constitutes a specialty class and title requiring the successful completion of an approved diploma program in infection prevention and control and specialty examination (Ordre des infirmières et infirmiers du Québec, 2019b).

Regulated Nursing in Canada: The Landscape in 2021 17 The clinical nurse specialist role first emerged in acute care hospitals in Canada during the 1960s and 1970s in response to rising patient acuity and growing complexity of patient care (Canadian Nurses Association, 2019a; Davies & Eng, 1995). The role was to support and improve nursing practice at the point of care. In the 1970s, masters-level education programs were established to facilitate clinical specialization, and several jurisdictions released position statements to define the scope of the clinical nurse specialist role. This scope was to include practice, education, research, consultation, and leadership (Registered Nurses’ Association of Ontario, 2012). However, cutbacks in the 1980s and 1990s led to the elimination of many clinical nurse specialist positions followed by a return of some positions to fill gaps in nursing practice created by losses of nurse educators and managers in the late 1990s (Canadian Nurses Association, 2006). In the 1990s, clinical nurse specialists were often hired in education and leadership positions, but this changed by the end of the decade with the role starting to focus more on supporting the implementation of evidence-based practices (Becker et al., 2012).

Determining the current number of clinical nurse specialists in Canada is challenging because of the lack of standardized regulatory and credentialing mechanisms to identify those who qualify as clinical nurse specialists and the absence of provincial or national processes to track these roles. In 2010, 2,200 nurses self-identified as clinical nurse specialists. However, they reported a mix of baccalaureate and master’s education rather than the recommended graduate education for the role (Canadian Institute for Health Information, 2012). Kilpatrick et al. (2011) identified only 800 master’s-prepared clinical nurse specialists in a 2009 survey with 93% working in urban settings and 62% working in in-patient units.

Today, clinical nurse specialists specialize in a specific area of practice that may be defined in terms of a population, a setting, a medical subspecialty, type of care, or type of problem (Canadian Nurses Association, 2014; DiCenso & Bryant-Lukosius, 2010b). They work collaboratively with interprofessional members of the health care team in different settings including hospitals, outpatient clinics, emergency departments, long-term care, community agencies, and homecare. Clinical nurse specialists provide an advanced level of nursing practice through the integration of in-depth knowledge and skills as clinicians, educators, researchers, consultants, and leaders (Canadian Nurses Association, 2009; Clinical Nurse Specialist Interest Group, 2009). Normally, their role is to provide clinical guidance and leadership to health care professionals managing complex care, to improve the quality of care, and to promote evidence-based practice (Canadian Nurses Association, 2019a). This includes educating and mentoring, generating new nursing knowledge, promoting the uptake of research into practice, developing and implementing new practices and policies, providing solutions for complex health care

18 issues and leading quality assurance and change initiatives (Canadian Nurses Association, 2009). In 2014, a Pan-Canadian initiative validated new core competencies for the clinical nurse specialist including clinical care, system leadership, advancement of nursing practice, and evaluation and research (Canadian Nurses Association, 2014).

To the best of our knowledge, Canada does not currently have a specifically titled clinical nurse specialist graduate education program. The University of Regina was offering a Clinical Nurse Specialist program which consisted of 11 online courses (8 nursing, 2 policy related, and 1 elective). Both registered nurses and registered psychiatric nurses were eligible for the program. However, according to their website, effective September 2019 admissions were suspended (University of Regina, 2020). Education for clinical nurse specialists typically occurs through generic graduate education programs that complement clinical expertise with broad-based knowledge and skills that can be applied to advanced practice nursing. For example, several universities, such as University of Manitoba, McMaster University, and University of Toronto state on their websites that they offer a master’s-based program that prepares graduates for a clinical nurse specialist role (McMaster University, 2020; University of Manitoba, 2020; University of Toronto, 2020a).

Several challenges have been identified in the implementation of clinical nurse specialist roles in Canada. There has been limited provincial, territorial or national investment in supporting the roles, a lack of formal education programs, no credentialing mechanisms, and a lack of title protection (DiCenso & Bryant-Lukosius, 2010b). This has resulted in contrasting situations where nurses with graduate education and a clinical specialty may be working as a clinical nurse specialist without the title while others who do not have clinical nurse specialist qualifications claim to be a clinical nurse specialist, leading to role confusion within and outside the profession (Donald et al., 2010a). In addition, there is a lack of role clarity with variations in working to full scope of practice, overlap with other provider roles, and the role’s broad-ranging use in different contexts (Bryant-Lukosius et al., 2010; Canadian Nurses Association, 2012; Charbachi et al., 2012).

General Comparison of Clinical Nurse Specialist Roles and Nurse Practitioner Roles While the roles of clinical nurse specialist and nurse practitioner share much in common, the one key difference is their scope of practice. In Canada, the legislated scope of practice for the clinical nurse specialist is the same as that of the registered nurse and additional legislation and regulations are not required. In general, the clinical nurse specialist spends proportionately more time on education, research, organizational leadership, and professional

Regulated Nursing in Canada: The Landscape in 2021 19 development activities and may have fewer responsibilities related to direct clinical practice (Canadian Nurses Association, 2009). In comparison, nurse practitioners have greater clinical role responsibilities and normally spend more of their work time providing direct patient care compared to other role activities (DiCenso & Bryant-Lukosius, 2010b). Therefore, nurse practitioners have expanded clinical functions and legislated authority to perform additional activities (e.g., diagnose, order tests, prescribe medication) (DiCenso & Bryant- Lukosius, 2010b).

Lack of title protection and confusion about clinical nurse specialist and nurse practitioner titles have been identified in the past (Schreiber et al., 2005). However, legislation throughout Canada has protected the nurse practitioner title, requiring registration with provincial and territorial regulators as a nurse practitioner in order to use the designation (Canadian Institute for Health Information & Canadian Nurses Association, 2006). Title protection is not in place for clinical nurse specialists (Bryant-Lukosius et al., 2010).

Nurse Midwives Midwifery was practised amongst Indigenous Peoples and European settlers long before Canada became a nation. Until the 19th century, it was practised as an everyday part of community life without regulation laws or professional organizations (Mason, 1987). Midwifery was integrated into the overall practice of nurses working in isolated areas, outposts, and nursing stations, and the extent to which it made up a major portion of their practice varied over time. Despite limitations on the practice, the profession of midwifery in Canada began to formally develop in the 1960s and 1970s with the formation of regional and national midwifery and nurse-midwifery organizations that had the common goal of legitimizing midwifery as a health-care profession. In the 1970s, work began to legalize midwifery, beginning in British Columbia and Ontario, and extending to Alberta in the 1980s (Relyea, 1992). Many different pressures and restrictions made practicing midwifery difficult until 1991, when Ontario legalized midwifery (Relyea, 1992).

Today in Canada, midwives are regulated health-care providers who care for healthy women and their newborn babies from early pregnancy, through labour and birth, until about six weeks postpartum. As primary care providers, midwives are fully responsible for clinical decisions and managing the course of a woman’s care. They can order and interpret tests, prescribe medications, make referrals to specialists, and catch babies. They work in pairs or small teams and are available to their clients 24 hours a day through the course of their care (Canadian Association of Midwives, 2020a).

Ontario, Alberta and British Columbia were the first provinces to regulate midwifery more than 25 years ago and today the majority of provinces and

20 territories have regulated and publicly-funded midwifery. Prince Edward Island is the only province without regulation and the Yukon is expected to pass legislation to regulate shortly. Although most midwives in Canada register to practise through their provincial or territorial governing college, several provinces and territories have legislation that waives that requirement for Indigenous midwives. Indigenous midwives who are registered with their regulatory authority may use the title Registered Midwife (or Midwife) and are legally permitted to carry out actions that are restricted to midwives through legislation (Canadian Midwifery Regulators Council, n.d.). Since regulation in the 1990s, the number of midwives in Canada has grown exponentially. In 2005, there were only 500 registered midwives, and in 2017 this grew to more than 1,690 with over half of these in Ontario. The number of midwives continues to grow steadily, as approximately 150 new midwives graduate from educational programs each year (Canadian Association of Midwives, 2020b).

The midwifery education program is a four year baccalaureate program culminating in a bachelor of health sciences in midwifery degree. There are currently seven midwifery education programs available in Canada: three in Ontario, one each in British Columbia, Alberta, Manitoba, and Quebec. Most education programs are direct entry, with no nursing or other credentials required for entry (Canadian Association of Midwives, 2020c). A post- baccalaureate program is also offered at Ryerson University with two years of full-time study if applicants have a previous health professional baccalaureate degree, such as nursing (Ryerson University, 2020). The Canadian Midwifery Regulators Council sets and administers the Canadian Midwifery Registration Exam. This exam is designed to assess Canadian-educated and internationally- educated applicants for midwifery registration to ensure they meet entry-level competency standards set out in the eight Canadian Competencies for Midwives (Canadian Midwifery Regulators Council, 2019), including,

1. Education and counselling, 2. Antepartum care, 3. Intrapartum care, 4. Care of client during the postpartum period, including breast/chest feeding 5. Care of the newborn and young infant, 6. Well-client care, sexuality and gynecology, 7. Professional, interprofessional, legal and other aspects of the profession, and 8. Professional development.

Regulated Nursing in Canada: The Landscape in 2021 21 SPECIALTY PRACTICE Specialty nursing practice is a branch of nursing that concentrates on a specific area of clinical nursing in which the focus of practice may be related to age (such as gerontology), an issue (such as infection prevention and control), a disease (such as cancer) or a practice setting (such as community health). The following criteria must be met to be defined as a specialty nursing practice area: health care system need and demand, specialized function, specialty association, national representation, standards of practice, specialty core competencies, core knowledge, education, advancement of nursing specialty and certification (Canadian Nurses Association, 2018).

There are currently 44 associations affiliated with the Canadian Nurses Association through the Canadian Network of Nursing Specialities, representing many of the professional, clinical, administrative, educational, and other interests of nursing. These organizations vary in size and scope, but their work tends to focus on the development and dissemination of knowledge, standards, and policy related to their specialty or area of interest. In addition, more than 16,000 nurses have become specialty certified by obtaining a credential from the Canadian Nurses Association that confirms their advanced specialty knowledge and skills. The Canadian Nurses Association Certification Program currently recognizes 22 nursing specialty areas for national certification, and, in 2019, the first certification for licensed practical nurses and registered psychiatric nurses were offered. A nurse who becomes certified in one of these areas is entitled to use a specialty credential(s) after their name. For instance, nurses certified in cardio-vascular nursing in Canada can use the CCN(C) designation (Canadian Nurses Association, 2015; Canadian Nurses Association, 2020b).

In some provinces and territories, the terms specialist, specialty, specialized practice, specialization and certification have particular meanings for regulatory purposes. Some refer to certain career paths that require additional registration requirements. In Alberta, a registered nurse or nurse practitioner may in accordance with the standards of practice use the title specialist in connection with providing professional services related to population, type of health problem, disease or subspecialty, practice setting or type of care. A nurse authorized to use the title specialist has a high level of expertise in a clinical specialty with three or more years of full-time experience in that clinical practice area and an applicable graduate degree (College and Association of Registered Nurses of Alberta, 2019a).

In Saskatchewan, registered nurse specialty practices include activities that are considered within the registered nurse’s scope of practice but are beyond

22 entry-level competencies (knowledge, skill, and judgment). These fall into two categories: registered nurse procedures and registered nurse clinical protocols. Registered nurse specialty practices apply to: 1) clients in an established health program and/or service (e.g., diabetes clinic, cardiac rehabilitation), 2) situations that are more complex and pose moderate to higher risk to the client (e.g., suprapubic catheter change, pelvic examination, suturing a simple laceration, the application of back slab cast), and 3) the management of some emergency care situations. The majority of registered nurses who work in specialized practice settings (e.g., intensive care unit, emergency room, maternal/newborn, public health, outposts and nursing stations) will engage in registered nurse specialty practices (Saskatchewan Registered Nurses Association, 2018a).

Regulated Nursing in Canada: The Landscape in 2021 23

Nursing Structures and Roles

Four pillars, or program areas, are essential to the oversight, governance and advancement of nursing in Canada:

• Regulation (protection of the public), • Professional practice (development, policy advocacy, and promotion of the profession), • Education, and • Labour relations (socioeconomic function).

In 1908, nursing groups and individuals across Canada came together to establish the Canadian Nurses Association to work on structuring the profession and protecting the public. The regulation and labour relations functions emerged from that shared beginning and over time assumed specific functions and responsibilities outside of the Canadian Nurses Association. Unions evolved to operate primarily within their statutory role as bargaining agents to improve the working conditions and compensation of nurses (Mildon, 2018). University educators were also brought together as a group within the Canadian Nurses Association, and eventually developed an independent association called the Canadian Association of Schools of Nursing. Within Canada today, these pillars continue to be advanced by a complex matrix of four nursing structures: regulatory bodies, professional associations, educational associations, and unions (Figure 2, page 26). While each of these structures have aims that are independent of each other they also work together on common issues. For example, a professional association and union may work together on policies affecting workplace violence. In addition, they may join with other non-nursing groups to form partnerships in the interest of public policy or specific nursing issues (Villeneuve, 2017).

Each structure may include a national organization as well as provincial/ territorial organizations, but these vary across the four regulated designations of nurses. For example, as shown in Table 3, there are 26 nursing regulators in Canada that include seven organizations with a combined mandate for a regulatory body and a professional association. In all provinces and territories, registered nurses and nurse practitioners are regulated under one authority. In British Columbia, Ontario, and Nova Scotia, all designations of nurses are regulated to practise in that province by one regulator. The remaining 10

Regulated Nursing in Canada: The Landscape in 2021 25 provinces and territories have separate regulatory bodies for the different designations. In the Yukon, Northwest Territories and Nunavut, licensed practical nurses are regulated by the government, and in the Yukon, registered psychiatric nurses are also regulated by the government. Adding to the complexity is that within each of the four regulated designations, an individual may have an affiliation or formal membership with associations at local/ regional, provincial, territorial, national and international levels (Villeneuve, 2017). In addition, some memberships are mandatory while others are voluntary. These issues are discussed in more detail in the following section.

Figure 2. Nursing Structures and Roles in Canada (Adapted from Villeneuve, 2018)

REGULATOR PROFESSIONAL EDUCATIONAL UNION

Advance Support Serve Advance the education the nurse and profession and and protect and represent strengthen the public improve nursing working health programs conditions

Table 3. Overview of Provincial, Territorial and National Organizations: Regulators and Professional Associations

NT BC AB SK MB ON QC NB NS PEI NL YT NU National Regulators RN, LPN, NP, RPN x RN, LPN, NP x x RN, NP x x x x x LPN x x x x x x x x x RPN x x Professional Associations RN, LPN, NP, RPN x x x RN/NP x x RN x LPN x NP x x x x x x x x x x Combined Regulator and Professional Association RN/NP x x x x x LPN x RPN x

Note: LPN = licensed practical nurses; RPN = registered psychiatric nurses; RN = registered nurses; NP = nurse practitioner

26 REGULATORS Self-regulation is generally understood to mean that a profession regulates itself through the creation of a regulatory body, rather than being managed by government (Canadian Nurses Association, 2007). It is based on the belief that the profession has the specialized knowledge necessary to set standards of practice and to evaluate the conduct of its own members (Storch, 2010). In Canada, nursing is a self-regulated profession, and all designations of nurses are regulated by their respective professional colleges under legislation found in provincial and territorial statutes. The legislation may be specific to nursing, such as a Nursing Act, or encompassed within umbrella legislation that applies to several different health-care providers, such as a Health Professions Act (Canadian Nurses Association, 2007). It is this legislation that gives nurses the authority to practise and provides the framework for governance of the profession. As noted in Table 4, the first regulated nursing legislation in Canada was passed in Nova Scotia in 1910 for registered nurses (Villeneuve, 2017), and the last legislation was passed in the Yukon in 2012 for nurse practitioners.

Table 4. First year of Regulation of Regulated Nursing Personnel by Province/Territory

BC AB SK MB ON QC NB NS PEI NL YT NY NU LPN 1988 1986 1956 1946 1947 1974 1960 1957 1959 1983 1987 1988 2011 RPN 1951 1955 1948 1960 ------2009 - - RN 1918 1916 1967 1913 1922 1946 1916 1910 1949 1954 1994 1973 1999 NP 2005 2002 2003 2005 1997 2003 2002 2002 2006 1997 2012 2004 2004

Note: LPN = licensed practical nurses; RPN = registered psychiatric nurses; RN = registered nurses; NP = nurse practitioner Source: Canadian Institute for Health Information. (2011).

The main responsibility of nursing regulatory bodies is to protect the public by ensuring uniform, high-quality regulatory practices (Canadian Nurses Association, 2007). With their mandate to protect the public, regulatory organizations do not take part in advocacy activities around health systems or nursing (Villeneuve, 2017). Protection of the public is achieved through the principles of promoting good practice, preventing poor practice, and intervening in unacceptable practice (Canadian Nurses Association, 2007). Nursing regulatory bodies have the mandate of articulating, promoting, and enforcing standards of practice and conduct. All regulated nurses in Canada are required to meet the basic professional standards and competency requirements of their respective regulatory bodies. Competencies refer to the knowledge, skills, judgment, and attributes required to practise safely and ethically in a designated role and setting (Canadian Nurses Association, 2010a). More detail for each designation is provided later in the report in the section on scope of practice.

Regulated Nursing in Canada: The Landscape in 2021 27 Regulatory bodies also establish registration criteria to determine whether applicants or members are eligible to practise in their jurisdiction. This includes establishing requisite skills and abilities and entry-level competencies (also called entry-to-practice competencies). The list and examples of requisite skills and abilities provide the public and practitioners with information about the nature of the activities and general demands of both education and practice. The entry-level competencies describe the minimum requirements or expectations of the new graduate required for safe, competent, and ethical practice (College of Licensed Practical Nurses of Manitoba, College of Registered Nurses of Manitoba and College of Registered Psychiatric Nurses of Manitoba, 2010). The competencies reflect theoretical and clinical preparation and the knowledge, skills, and judgment required to practise. They are normally reviewed every five years to ensure inter-jurisdictional consistency and practice relevance. Revisions are based on each regulatory body’s ongoing evaluation of the practice environment and data collected from new graduates and employers on required entry-level practice skills and roles. The regulatory body in each jurisdiction validates and approves the entry-level competencies and confirms they are consistent with provincial/territorial legislation. Regulatory bodies assess entry-level competencies in the jurisdictions where nursing candidates have graduated through academic program approval/evaluation and the Canadian registration exams (College of Licensed Practical Nurses of Manitoba, College of Registered Nurses of Manitoba and College of Registered Psychiatric Nurses of Manitoba, 2010; Saskatchewan Registered Nurses Association, 2019b; Villeneuve, 2017; Yoder-Wise, 2016). More detail regarding registration criteria, requisite skills and abilities, and entry-level competencies specific to each nursing designation is provided later in the report under scope of practice.

Over the past few years, several jurisdictions have also introduced a jurisprudence examination or module as a registration requirement. Jurisprudence examinations measure an individual nurse’s awareness of provincial regulatory policies and any provincial and federal laws that would relate to nursing practice in their jurisdiction. Once registered, the names of individuals who meet all registration requirements are listed in an official register and nurses are held accountable to the standards, limits, and conditions established by their regulatory body (Canadian Nurses Association, 2007; Garrett & MacPhee, 2014). To support workforce mobility, the federal/provincial Agreement on Internal Trade stipulates that jurisdictional regulatory bodies recognize those licensed professionals who move between provinces and territories and work collaboratively on harmonizing registration requirements to support such mobility, where possible (Canadian Nurses Association, 2015).

Recognizing the need for improved national collaboration and communication between provincial and territorial nurse regulators, a Canadian Nurse Regulators Collaborative was formed with a forum held in July 2017. This was the first

28 ever gathering of all nurse regulators in Canada, including the Council for Practical Nurse Regulators, Canadian Council for Registered Nurse Regulators and Registered Psychiatric Nurse Regulators of Canada. The forum provided the opportunity to learn more about each designation, and to exchange knowledge and information. This collaborative continues to work on common priorities and issues (Council for Practical Nurse Regulators, 2016).

Licensed Practical Nurse Regulators In 1946, Manitoba was the first province requiring licensed practical nurses to register with a regulatory body as a condition of practice. By 1988 most provinces and territories had regulation in place, with Nunavut passing legislation in 2011. Today, licensed practical nurses are regulated in all 13 provinces and territories. In the provinces, regulation occurs through a combination of provincial legislation and provincial colleges or associations. In the Yukon, Northwest Territories and Nunavut, it is managed through territorial legislation. Eleven of the provincial/territorial bodies have only regulatory mandates, with the exception of the Association of New Brunswick Licensed Practical Nurses, which maintain dual regulatory (regulation of the profession) and professional (advocacy) functions (Villeneuve, 2017).

Founded in 2004, the Canadian Council for Practical Nurse Regulators is a federation of provincial and territorial organizations responsible for the regulation of licensed practical nurses. Representatives of 10 practical nurse regulatory authorities in Canada were the first members of the Canadian Council for Practical Nurse Regulators with an initial mandate to promote excellence in practical nursing regulation by demonstrating leadership, best practice, and innovation. Today, the Canadian Council for Practical Nurse Regulators provides a forum to discuss and collaborate on issues and initiatives relevant to the regulation of practical nurses (Canadian Council for Practical Nurse Regulators, 2020).

Registered Psychiatric Nurse Regulators Registered Psychiatric Nurses were first regulated in Saskatchewan in 1948, followed by British Columbia in 1951, Alberta in 1955 and Manitoba in 1960. Regulation in the Yukon occurred in 1990 under their Health Professions Act resulting in Yukon becoming the first territory to regulate registered psychiatric nurses (Registered Psychiatric Nurse Regulators of Canada, 2015a). Each of the four provincial jurisdictions (Manitoba, Saskatchewan, Alberta and British Columbia) have a regulatory body with only the Registered Psychiatric Nurses Association of Saskatchewan maintaining a dual regulatory and professional function (Villeneuve, 2017). In the Yukon, registered psychiatric nurses are regulated by the government. Outside of the western provinces and Yukon, the registered psychiatric nurse profession and scope is not defined in legislation

Regulated Nursing in Canada: The Landscape in 2021 29 and formal regulatory structures do not currently exist, thereby restricting them from practicing their profession in other parts of Canada. While they may work anywhere in Canada, they cannot practise to the scope of a registered psychiatric nurse (Registered Psychiatric Nurse Regulators of Canada, 2015a).

Formerly known as the Registered Psychiatric Nurses of Canada, the Registered Psychiatric Nurse Regulators of Canada represents the four western provincial jurisdictions and the Yukon, and oversees the Registered Psychiatric Nurses of Canada entry-to-practice examination. Registered Psychiatric Nurse Regulators of Canada is not a regulator itself but a virtual organization whose members are the formal regulatory bodies from the four provinces. The Board of Directors is formed of the presidents/chairs and executive directors/registrars of the member organizations (Registered Psychiatric Nurse Regulators of Canada, 2015a).

Registered Nurse Regulators The first legislation for registered nurses was passed in Nova Scotia in 1910 and allowed for voluntary registration. The first registration act was passed in Manitoba in 1913, and by 1922 all nine existing provinces had some form of legislation for registered nurses (Villeneuve, 2017). Today, registered nurses are regulated in all provinces and territories. Other than in Ontario, where the College of Nurses of Ontario and the Registered Nurses’ Association of Ontario have been separate organizations since 1963, registered nurse associations in the provinces and territories have historically housed both the regulatory and professional association functions (Balaski, 2018). This is different than the other nursing designations who historically have either had separate regulatory colleges and professional associations or no professional associations, with a few exceptions noted. Generally speaking, the difference in the purpose and function of each regulatory body lies largely in legislation which either combines the regulatory and professional association roles or separates them (Schiller, 2014).

In more recent years, from a regulatory and professional practice perspective, arguments were made that a nursing association could not regulate registered nurses in the interest of the public while simultaneously advocating for or promoting the profession (Mildon, 2018). Some regulatory bodies self-identified this conflict and independently initiated a separation of their regulatory and professional association roles (e.g., College of Registered Nurses of British Columbia in 2011). Other provinces were mandated by legislation to separate the functions (e.g., Manitoba in 2015 and Nova Scotia in 2018) (Balaski, 2018; Mildon, 2018). All three provinces have moved to a model similar to Ontario, with separate regulatory and professional associations. Some believe

30 separation of these functions is a positive change, removing any perceptions of bias, self-promotion, or impropriety (Balaski, 2018; Mildon, 2018).

In addition to each province and territory having its own college/regulator, all regulatory bodies are members of a national regulatory group. The Canadian Council of Registered Nurse Regulators was formed in 2011 and membership includes representatives (typically the executive leader) of the body that regulates registered nurses from each province and territory (Canadian Council of Registered Nurse Regulators, 2018a). The Canadian Council of Registered Nurse Regulators promotes excellence in professional nursing regulation in the public interest and serves as a national forum and voice regarding interprovincial/territorial, national, and global matters for nursing regulation. The Council‘s priorities focus on helping Canada’s 12 registered nurse regulators to collaborate on approaches in key regulatory areas such as registration, policy, and practice, nursing education program approval, professional conduct, and quality assurance/competence (Canadian Council of Registered Nurse Regulators, 2018a).

Nurse Practitioner Regulators The first nursing legislation which included the nurse practitioner’s legislated authority, scope of practice, and regulation was passed in British Columbia and Ontario in 1997. Today, nurse practitioners are regulated in all provinces and territories with the Yukon passing legislation in 2012. In all provinces and territories, registered nurses and nurse practitioners are under the same regulatory body and legislation. Differentiation is made between the registered nurse and nurse practitioner within the legislation and regulations where applicable, such as scope of practice, registration requirements, controlled acts, restricted activities or reserved acts, entry-level competencies, and standards of practice.

PROFESSIONAL ASSOCIATIONS Professional nursing associations advance the practice of nursing and involve advocacy on behalf of the nursing profession to shape and inform decisions about health care and public policy. These associations have regional or national collectives and may be connected internationally through the International Council of Nurses, which serves as a unified, global voice for nursing (Yoder-Wise, 2016). Professional nursing associations carry out a great deal of this work through collective action on a variety of topics, including changes to nursing practice, care delivery models, public health care, publicly funded health care, housing, poverty reduction, climate change and medical assistance in dying. They also provide guidance and expertise to nurses around practice and policy issues, and to non-nurse organizations requiring a nursing perspective or contribution (Villeneuve, 2017; Yoder-Wise, 2016).

Regulated Nursing in Canada: The Landscape in 2021 31 Historically, the national professional nursing associations have included the Canadian Nurses Association for registered nurses and nurse practitioners, Practical Nurses Canada for licensed practical nurses and Nurse Practitioners Association of Canada for nurse practitioners. Registered psychiatric nurses have not had a national professional association, however they have had professional associations in some provinces. Starting in 2019, the Canadian Nurses Association opened its membership to include licensed practical nurses and registered psychiatric nurses. Provincially, there is a lack of consistency across the country. British Columbia recently formed a professional association for all categories of regulated nurses. Some provinces have a combined regulator/professional association or a sole professional association for some regulated designations but not others, while other provinces have no official professional association for some designations.

Licensed Practical Nurses’ Professional Associations In 1975, the Canadian Association of Practical and Nursing Assistants was incorporated to create a unified voice and a national association representing provincial/territorial licensed practical nurse organizations across Canada. This Association would later become an affiliate member of the Canadian Nurses Association. Over the next decade, the Canadian Association of Practical and Nursing Assistants worked with the provincial/territorial associations and government on promoting high standards of nursing education, ensuring uniformity of curriculum content, endorsing standardization and registration of practical nurses in all of Canada, interpreting the Practical Nurse/Nursing Assistant’s role on the health care team, safeguarding the interest and maintaining the autonomy of the licensed practical nurse, registered nursing assistant, and certified nursing assistant, and promoting mutual understanding and unity among all provincial/territorial associations (Fredrickson et al., 2003).

In 1981, Quebec withdrew from the Canadian Association of Practical and Nursing Assistants, and the Association did not apply for affiliate membership in the Canadian Nurses Association. The following decade was one of uncertainty due to changes taking place with registered nurses’ education and plans to make the baccalaureate degree the minimum level of entry to practice by the year 2000. This change threatened the future of the practical nurse/nursing assistant designation. The number of full-time positions was decreasing, duties were being redefined, and practical nurses/ nursing assistants were being replaced through attrition and being moved out of specialty units. Lastly, the Canadian Association of Practical and Nursing Assistants was no longer being included on Advisory Committees within government, such as the Canadian Council on Hospital Accreditation (Fredrickson et al., 2003).

In 1988, the word nurses was added to the Association’s title to become The Canadian Association of Practical Nurses and Nursing Assistants. The 32 Association gained momentum again in the late 1990s, with several ground- breaking initiatives including the production of the profession’s first national standards by the College of Licensed Practical Nurses of Alberta in 1999. In 2000, due to legislative changes in Nova Scotia, the Licensed Practical Nurses Association of Nova Scotia was forced to close after 41 years of activity. Across the country, legislation was taking place in every province with changes to regulations and titles, such as registered nursing assistant to licensed practical nurse (Fredrickson et al., 2003). In 2006, Canadian Association of Practical Nurses and Nursing Assistants’ name was changed to Practical Nurses Canada (Villeneuve, 2017). No further information is available regarding Practical Nurses Canada.

Today, four provinces maintain professional associations for licensed practical nurses. Ontario has had a stand-alone professional association since 1958, WeRPN (previously the Registered Practical Nurses of Ontario). British Columbia has a professional association that also includes registered nurses, registered psychiatric nurses and nurse practitioners. New Brunswick has a dual regulatory/professional association. In 2020, the Association of Registered Nurses of Manitoba voted to expand its membership to include all regulated nurses and changed their name to the Association of Regulated Nurses of Manitoba (Association of Regulated Nurses of Manitoba, 2020). There is currently no professional representation for licensed practical nurses in the other jurisdictions. Since 2019, licensed practical nurses can join the Canadian Nurses Association directly.

Registered Psychiatric Nurses’ Professional Associations Three provinces maintain professional associations for registered psychiatric nurses. Saskatchewan has a dual regulatory/professional association. The Association of Registered Psychiatric Nurses of British Columbia was a stand- alone professional association in British Columbia until 2018 when it merged with other professional nursing associations in the province to form Nurses and Nurse Practitioners of British Columbia which also includes registered nurses, licensed practical nurses and nurse practitioners. As noted previously, in 2020 the Association of Registered Nurses of Manitoba voted to expand its membership to include all regulated nurses and changed its name to the Association of Regulated Nurses of Manitoba (Association of Regulated Nurses of Manitoba, 2020). Since 2019, registered psychiatric nurses can join the Canadian Nurses Association directly.

Registered Nurses’ Professional Associations In 1907, the Canadian Society of Superintendents of Training Schools for Nurses was formed (Ross-Kerr & Wood, 2011) and was the first Canadian national organization of nurses. The next year the society invited representatives of 16 individuals and organized nursing bodies in Canada to

Regulated Nursing in Canada: The Landscape in 2021 33 meet to establish a national association of nurses. Pre-dating regulation, the result of the meeting was the inception of the Canadian National Association of Trained Nurses (Ross-Kerr & Wood, 2011; Yoder-Wise, 2016). The association applied for membership in the International Council of Nurses in 1908 and formal admission to membership in the world body took place the next year (Ross-Kerr & Wood, 2011). By 1924, each of the nine provinces had a professional nursing association with membership in the Canadian National Association of Trained Nurses, and the national group changed its name to the Canadian Nurses Association (Yoder-Wise, 2016). The Newfoundland association would join later when the province joined Canada; the Northwest Territories joined in 1975 and Yukon in 1982.

The Canadian Nurses Association was originally the single national body representing all domains of nursing (regulatory policy, the socio-economic welfare of nurses, education, and professional issues and advocacy). The Provisional Council of the Canadian Association of University Schools and Departments of Nursing first met in 1924 with representatives from eight university schools and departments of nursing. The council was part of the Canadian Nurses Association structure at various points in history, then eventually separated to become the Canadian Association of Schools of Nursing (see more details following). Advocacy for the compensation, safety, and workplace satisfaction of nurses was also a pillar of activity within Canadian Nurses Association. As early as 1924, the association was generating reports for the federal government using statistics to describe current trends and issues. By 1943, the Canadian Nurses Association had put in place its first formal Committee on Labour Relations. Over time, union organizations were formed throughout the provinces and the National Federation of Nurses Unions was formed in 1981 (see more details following) (Villeneuve, 2017).

At the provincial and territorial level, registered nursing regulatory colleges and professional associations have been part of the same organizations since most were established, except for Ontario where the Registered Nurses Association of Ontario became a stand-alone professional association after the establishment of the College of Nurses of Ontario. Over the decades, a universal membership model was implemented wherein registered nurses automatically became members of their provincial or territorial association when they registered to practise with their regulatory body. In turn, they would automatically have membership in the Canadian Nurses Association and the International Council of Nurses through their jurisdictional membership. In Ontario, nurses who joined the Registered Nurses Association of Ontario through voluntary membership would then have automatic membership in the Canadian Nurses Association (Villeneuve, 2017). All Canadian jurisdictions had member organizations at the Canadian Nurses Association table until 1985 when the Ordre des infirmières et infirmiers du Québec withdrew

34 (Elliott et al., 2013). Since 2014, nurses from Quebec could join the Canadian Nurses Association as independent members. In 2016, the Registered Nurses Association of Ontario also withdrew from the Canadian Nurses Association which led to the formation of CNAOntario in 2017 allowing nurses in Ontario to voluntarily join (Villeneuve, 2017).

In recent years, British Columbia, Manitoba and Nova Scotia each have made changes to separate the regulatory and professional roles, similar to the model in Ontario. This change initially led to a void in the nursing professional practice/association function in these jurisdictions. However, these were filled by nurses coming together in British Columbia and Manitoba to establish new stand-alone professional associations: the Association of Registered Nurses of British Columbia (now Nurses and Nurse Practitioners of British Columbia) and the Association of Registered Nurses of Manitoba (now Association of Regulated Nurses of Manitoba). CNA Nova Scotia was recently formed until a provincial association is established and becomes a jurisdictional member of the Canadian Nurses Association. Some believe that the separation of these functions will weaken the voice of the profession. While membership in a college/regulator is mandatory, involvement in an association is voluntary. In this regard, associations rely on nurses to understand the importance of the advocacy role and choose to be involved through paid membership (Balaski, 2018; Mildon, 2018).

Historically, membership within the Canadian Nurses Association included only registered nurses and nurse practitioners. Today, the Canadian Nurses Association represents all regulated nurses in 13 jurisdictions as well as retired nurses from across the country. Its mission is to advance the practice of nursing and the profession to improve health outcomes in a publicly funded, not-for- profit health system by unifying the voices of nurses, strengthening nursing leadership, promoting nursing excellence and a vibrant profession, advocating for healthy public policy and a quality health system, and serving the public interest (Canadian Nurses Association, 2019b).

Nurse Practitioners Professional Associations In 1979, the Clinical Nurse Specialist Association of Ontario was founded for clinical nurse specialists as an interest group and a member of the Registered Nurses Association of Ontario (Clinical Nurse Specialists Association of Ontario-Canada, 2020). Ten years later, in 1989, the Canadian Clinical Nurse Specialist Interest Group was formed and transitioned to the Canadian Association of Advanced Practice Nurses in 1997 (Carter et al., 2010). For 20 years, the Canadian Association of Advanced Practice Nurses provided leadership to address policy, practice, and education issues affecting both clinical nurse specialists and nurse practitioners at the national level. Over time,

Regulated Nursing in Canada: The Landscape in 2021 35 the decision was made to create separate associations. In 2015, the Clinical Nurse Specialist Association of Canada was established and is a member of the Canadian Network of Nursing Specialties (Clinical Nurse Specialist Association of Canada, 2020; Canadian Nurses Association, 2016b). This association provides a leadership platform that helps clinical nurse specialists influence health system change to support safe, quality care and superior outcomes (Canadian Nurses Association, 2016b; Clinical Nurse Specialist Association of Canada, 2020).

In 2017, the Nurse Practitioner Association of Canada was established and is also a member of the Canadian Network of Nursing Specialties. It is the national Canadian organization with over 1,300 members consisting of nurse practitioners and nurse practitioner students, encompassing a multitude of specialties. As the national voice for nurse practitioners, its goal is to advocate for, and reduce barriers to nurse practitioner practice (Nurse Practitioner Association of Canada, n.d. a). Each province also has a professional association, but there are none listed for the territories (Nurse Practitioner Association of Canada, n.d. b). Membership in the professional association provides nurse practitioners with educational opportunities, networking, advocacy services, and professional support. Nurse practitioners voluntarily join the professional association within their province, and in some provinces their fees include a membership in the Nurse Practitioner Association of Canada while others do not. In the provinces that do not offer a block member through a provincial partnership, nurse practitioners can join through an individual member or a small group membership for groups without the ability to join via a provincial partnership agreement (Nurse Practitioner Association of Canada, n.d. c).

EDUCATIONAL ASSOCIATIONS Educational nursing associations provide a voice and leadership for nursing education in Canada through national associations and provincial councils in some provinces. They contribute to policy initiatives related to issues and trends in education, establish and promote national standards of excellence for nursing education, liaise with key stakeholders such as government and regulatory bodies on issues pertaining to educational needs, and provide a forum for issues in nursing education and research (Canadian Association of Practical Nurse Educators, 2020; Canadian Association of Schools of Nursing, 2019a). While national education associations exist for licensed practical nurses, registered nurses, and nurse practitioners, a similar association does not exist for registered psychiatric nurses.

36 Licensed Practical Nurses Education Associations The Canadian Association of Practical Nurse Educators is the national voice for practical nursing education in Canada with jurisdictional representation from 11 provinces and territories. Their objectives include:

• Supporting and enhancing the quality of practical nursing education • Promoting evidence-informed education • Liaising with key stakeholders such as government and regulatory bodies on issues pertaining to educational and human resource needs • Enhancing awareness and understanding of the practical nurse role • Contributing to policy initiatives related to issues and trends in health and education • Promoting collaboration with other educators and enhancing interprofessional education and practice • Supporting and fostering transferability between educational programs and mobility of graduates, and • Overseeing the organization of an annual conference (Canadian Association of Practical Nurse Educators, 2020).

Registered Nurses and Nurse Practitioners Education Associations The Canadian Association of Schools of Nursing is the national voice for registered nurse and nurse practitioner education, research, and scholarship. The association represents baccalaureate and graduate nursing programs in Canada (Canadian Association of Schools of Nursing, 2019a). In 1942, university educators were brought together for the first time as the Provisional Council of the Canadian Association of University Schools and Departments of Nursing, a group within the Canadian Nurses Association (Baker, Guest, Jorgenson, Crosby & Boyd, 2012). In 1949, this group formed an organization independent from the Canadian Nurses Association and renamed itself the Council of University Schools and Departments of Nursing. The organization’s name changed again in 1950 to the Canadian Conference of University Schools of Nursing and its focus was on: a) providing an organized body to speak for nursing education in Canada and facilitating the exchange of information and ideas, b) determining standards for Canadian university schools of nursing, c) strengthening and supporting the development of nursing education, d) strengthening relationships between universities schools of nursing in Canada and e) supporting the development of stronger relationships between education programs (Kirkwood & Bouchard, 1992, cited in Baker et al., 2012).

In 1969, a new structure was implemented within the Canadian Conference of University Schools of Nursing with a Council of Deans and Directors of member

Regulated Nursing in Canada: The Landscape in 2021 37 institutions and four regional associations formed (Western North-Western, Ontario, Québec, Atlantic). This reorganization introduced institutional rather than individual membership, with schools of nursing being the members rather than individual educators (Kirkwood & Bouchard, 1992, cited in Baker et al., 2012). The Western North-Western Region includes the four Western Provinces and the Northwest Territories. The Ontario Region includes the Council of Ontario University Programs in Nursing and the Colleges of Applied Arts and Technology Nursing Schools. Quebec is represented by the Quebec region, and the Atlantic Region includes the four Atlantic provinces (Canadian Association of Schools of Nursing, 2019b). In 1971, the name was changed to the Canadian Association of University Schools of Nursing (Baker et al., 2012). In 1997, the Canadian Association of University Schools of Nursing started focusing more on graduate nursing education by introducing a meeting on Graduate Studies during the annual November council meeting. The annual Forum has continued with increasing attendance over the years reflecting the continuing growth of graduate programs (Baker et al., 2012).

The new millennium brought a significant change to the organization with collaborative college partners of universities beginning to attend council meetings as associate, non-voting members. With the implementation of the baccalaureate degree as entry to practice, and collaborations between universities and colleges developing across the country, there was a need to acknowledge the change in the delivery of nursing education, reorganize, and restructure. In 2002, the council adopted a new governance structure and, to reflect the new membership composition,University was taken out of the Association’s name to become the Canadian Association of Schools of Nursing (Baker et al., 2012). Although a council of deans and directors was maintained, it now elects the board of directors and officers, and the board of directors oversees the association and is the policy making body. The board represents the four regional associations: Ontario, Quebec, Atlantic and Western North-Western.

Today, the Canadian Association of Schools of Nursing continues to be a voluntary association that promotes the advancement of nursing knowledge; facilitates the integration of theory, research, and practice; contributes to public policy; and speaks for Canadian nursing education and scholarship. It is representative of all universities and colleges offering part or all of an undergraduate or graduate degree in nursing. It is also the national accrediting body for nursing education in Canada, with the Canadian Association of Schools of Nursing Accreditation Bureau operating at arms-length from the council and the board (Canadian Association of Schools of Nursing, 2019a).

38 NURSING UNIONS The first provincial nursing union was established in Saskatchewan in 1973, and others were established in the rest of the provinces and territories over the next 14 years (Villeneuve, 2017). In 1981, the National Federation of Nurses Unions was created to represent unionized nurses at the national level (Tazbir, 2013) and, in 1998, became a member of the Canadian Labour Congress, which provided support for collective bargaining. In 1999, the name was changed to the Canadian Federation of Nurses Unions. While the focus was initially on negotiating contracts, grievances, and other labour relations issues, the work evolved to include health care system and social justice concerns and advocacy.

Gradually, provincial nursing unions joined the national collective, with the exception of the Fédération des Infirmiers et Infirmières du Québec (name changed to the Fédération interprofessionnelle de la santé du Québec in 2006 to represent different health professions). The British Columbia Nurses Union initially joined then withdrew membership in 2011. Both of these provincial unions continue to attend national board meetings and conventions as observers (Tazbir, 2013).

Today, the Canadian Federation of Nurses Unions is the voice of nearly 200,000 unionized nurses and nursing students across Canada and it represents nurses’ unions in eight provinces (Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland and Labrador) (Canadian Federation of Nurses Unions, 2019). Prior to the unionization of nursing, nurses were paid very low wages and worked extremely long hours in unsafe environments (Balaski, 2018). Nursing unions have made significant gains in nursing salaries, working conditions, and policy for public health care and safety (Villeneuve, 2017).

Depending on their category, employer, and province/territory of employment, all regulated nurses may join provincial nursing unions, or they may belong to larger, multi-occupational unions (Villeneuve, 2017). Union stewards or regional representatives are elected to represent unionized nurses within regions, practice settings, or both. The Canadian Federation of Nurses Unions is not involved directly in the business of the provincial associations but rather serves as a unifying focal point and force for advocacy and other action by the collective membership. Internationally, the Canadian Federation of Nurses Unions is connected with Global Nurses United, which brings together 23 unions in 18 countries. While the Canadian Federation of Nurses Unions’ individual members include registered nurses in the eight provinces, the organization also represents licensed practical nurses, registered psychiatric nurses, and nurse practitioners in various provinces. Until the recent changes with Canadian Nurses Association membership, the Canadian Federation of Nurses Unions was the only national nursing organization having all four designations of nurses as members (Villeneuve, 2017).

Regulated Nursing in Canada: The Landscape in 2021 39 40 Nursing Education

Provincial and territorial legislation provide regulatory bodies the legislated responsibility to approve entry-level nursing programs for all designations of regulated nurses within their jurisdiction by ensuring programs meet specific standards and to improve the program quality through regular reviews. In general, these standards focus on the program structure and/or administration, curriculum, students, graduates, faculty, and outcomes or program effectiveness (College and Association of Registered Nurses of Alberta, 2018; College of Nurses of Ontario, 2019a; College of Registered Psychiatric Nurses of Manitoba, 2014). Program approval is compulsory for education programs as compared to accreditation which is voluntary in nature.

Historically, the Canadian Association of Schools of Nursing Accreditation Program has been the national accrediting body for registered nurse education in Canada, however, work is underway to also offer accreditation for practical nurse and nurse practitioner education. The Canadian Association of Schools of Nursing Accreditation Program is guided by standards divided into two sets; one applies to the school of nursing itself, referred to as the educational unit, and the other applies to the nursing education program. The educational unit standards assess the administrative structures, processes, and the human and material resources while the nursing education program standards focus on the curriculum and its evaluation (Canadian Association of Schools of Nursing, 2014). As accreditation has evolved, several jurisdictions have chosen to blend the voluntary Canadian Association of Schools of Nursing Accreditation Program with the mandatory regulatory program approval. The integration of approval of schools and accreditation now involves the majority of schools of nursing in Canada (Baker et al., 2012). Appendix A provides a summary of a number of approved nursing education programs for each regulated nurse designation in each province and territory.

Educational programs are foundational to the preparation of all regulated nurses. It is the educational programs that ensure that graduates entering the profession can demonstrate the entry-level competencies and competency requirements of their respective regulatory bodies. While the four regulated designations share some of the same theoretical preparation and basic competencies, there are fundamental differences in their educational preparation in terms of the focus, core content studies, and depth and breadth of the theory. Registered nurses and registered psychiatric nurses study for a longer period of time allowing for greater depth and breadth of foundational

Regulated Nursing in Canada: The Landscape in 2021 41 knowledge in clinical practice, decision-making, critical thinking, leadership, research utilization, and resource management. However, while general nursing knowledge is part of the psychiatric nursing curriculum, the primary emphasis is highly developed skills and knowledge in mental health and addictions and advanced therapeutic relationships and communication. The breadth and depth in these areas distinguishes psychiatric nursing education from the other nursing programs (Registered Psychiatric Nurse Regulators of Canada, 2015a).

The licensed practical nurse program is shorter in length with a more focused foundational knowledge of clinical practice, decision-making and critical thinking (Baumann et al., 2009). Nurse practitioner programs are at a graduate level where they build on the undergraduate education and clinical experience to develop an in-depth knowledge of advanced nursing practice and theory, health management, health promotion, disease/injury prevention, and other relevant biomedical and psychosocial theories to provide comprehensive health services. As nurses move throughout their careers, they also build on their entry-level competencies through various methods of learning.

LICENSED PRACTICAL NURSE EDUCATION The first practical nurse school in North America was located in Brooklyn, New York in 1893 and admitted candidates from all over the United States and Canada (Fredrickson et al., 2003). In Canada, programs for practical nurses were introduced in provinces across the country between 1939 and 1960, 65 years later than registered nurses’ education and 20-25 years later than registered psychiatric nurses’ education (Pringle et al., 2004).

In 1939, the Canadian Nurses Association recommended that each province develop educational programs for practical nurses as a solution to a shortage of nurses that had increased as a result of World War II (Mussallem, 1960). In 1941, the Registered Nurses Association of Ontario implemented a demonstration program for nursing assistants in Ontario, and in 1943 the St. Boniface School for Practical Nurses opened its doors in Manitoba (Kozier, 2014; Pringle et al., 2004). These earliest programs were less than a year in length and most required students to have completed only elementary school. Programs in most provinces were also run by the government, such as the department of Public Health or Education (Pringle et al., 2004).

During the 1950s, programs were transferred to the vocational training sectors of the provinces. Over the next 30 years, most programs were relocated to colleges, and in some provinces to high schools and hospitals. The entering credentials and course requirements were increased, provincial and territorial professional practical nursing associations (or their equivalents) were granted authority to approve program curricula, and registration became mandatory

42 (Pringle et al., 2004). During the 1980s, most educational programs migrated to diploma programs in community colleges. The exception was Quebec, which continued to house its 18- to 24-month programs in vocational schools under the authority of local boards of education (Pringle et al., 2004). The rationale for creating the diploma programs was that advancing technology, increased demands in community care, and changing skill mix required an expansion of the practice of licensed practical nurses (Baumann et al., 2009).

Since 1990, a number of significant changes have occurred in the education of licensed practical nurses, though these are not uniform across the provinces:

1. Changes in legislation allowed licensed practical nurses to carry out and/or initiate certain medical procedures that were previously only permissible for registered nurses and registered nurses with extended class designation to perform. An important reason for the modification of the curriculum was to ensure that graduates had the knowledge and skills to practise according to the changes in legislation (Baumann et al., 2009). 2. The profession sought to address the diversity in licensed practical nursing education and practice across Canada, and work toward educational changes to decrease the diversity in educational preparation (Pringle et al., 2004). 3. The Canadian Nurses Association spearheaded the National Nursing Competencies Project in the early 1990s with the goal of mapping the shared and unique competencies expected of entry- level practitioners for licensed practical nurses, registered nurses, and registered psychiatric nurses. A new set of skills was identified for licensed practical nurses that previously was only within the registered nurses’ scope of practice. While licensed practical nurses were expected to acquire them through continuing education programs, these changes also had an effect on lengthening the educational programs with new expanded competencies being included in the curriculum (Pringle et al., 2004). 4. Changes in the entry to practice for registered nurses, also offered the opportunity for licensed practical nurse programs to adjust their education requirement to include diploma programs and expand their scope of practice with a corresponding increase in the length of the educational programs (Pringle et al., 2004).

Today, licensed practical nurses receive their theoretical and clinical education through diploma programs typically offered through community colleges as well as private educational institutions. The length of programs across Canada vary from approximately 16 to 24 months, with British Columbia having programs shorter in length than other provinces based on a review of websites.

Regulated Nursing in Canada: The Landscape in 2021 43 REGISTERED PSYCHIATRIC NURSE EDUCATION Education programs for registered psychiatric nurses are confined to Western Canada. The first education program was established in 1920 in Manitoba at the Brandon Asylum and became a model for programs that were developed a decade later in other provinces. The program was under the Minister of Public Works and was two years in length. Courses were related to psychiatry, general nursing and obstetrics and classes were taught by medical staff and the asylum’s matron (Refvik, 1991). On completion, students received a Diploma in Mental Nursing. Programs in the other three western provinces were all established in 1930 or 1931 with a Diploma in Psychiatric Nursing received on graduation.

During the war, the programs struggled due to male attendants leaving to serve in the war and the nursing staff were stretched to manage the facilities. As a result, programs were reduced from up to 500 hours of class time to 100 hours and were no longer viewed as adequate. In Saskatchewan, the province examined the future of the psychiatric nursing programs and the decision was made to enhance the programs at the mental hospitals by increasing to three years in length with 500 hours of classes. The curriculum was largely developed by psychiatrists with teaching done by physicians, psychiatrists, and nursing staff. This program remained in effect in Saskatchewan until the early 1970s. In Manitoba from 1943 to 1957, a four-year combined program between the Brandon Mental Health Centre and the Winnipeg General Hospital prepared nurses as both general (registered) nurses and psychiatric nurses (Registered Psychiatric Nurses Association of Manitoba, 1977, cited in Pringle et al., 2004).

Beginning in 1948, in Saskatchewan, and later in other provinces, legislation was initiated to recognize psychiatric nursing as a distinct profession and to transfer the control of the education programs to psychiatric nursing councils. While the original programs were under the authority of the provincial governments, the medical superintendents of the hospitals were directly responsible for them. In 1960, in Manitoba, the government created the Psychiatric Nurse Education Advisory Committee, which had responsibility for establishing admission criteria, curriculum, and examinations (Registered Psychiatric Nurses Association of Manitoba, 1977, cited in Pringle et al., 2004). However, this committee was chaired by a psychiatrist and dominated by psychiatrists and medical directors of hospitals. It was not until 1980 that further legislation in Manitoba gave the College of Registered Psychiatric Nurses the mandate to approve the educational programs. Similar developments occurred in the other provinces with the passing of psychiatric nursing acts that gave control of programs to councils controlled by psychiatric nurses (Pringle et al., 2004).

44 Beginning in the early 1970s, a shift occurred in every province when programs were transferred from psychiatric hospitals to colleges and universities. By the end of the 1990s, no programs were based in mental hospitals, and all had to meet standards set by provincial psychiatric nursing councils. The era of psychiatrist control and apprenticeship-based programs was over, and many faculty members who taught in the programs had trained as registered psychiatric nurses. However, the structure of the programs across the four provinces differed:

• The first program to transfer was in British Columbia in 1971 with a program started at the British Columbia Institute of Technology in 1972 and later transferred to Douglas College in 1984. The first year of the program was combined with the program to prepare registered (generalist) nurses until it was restructured and separated in 1978. Today two institutions offer a baccalaureate degree and one institution offers a diploma, with length of programs ranging from 2.5 to 4 years. • Alberta moved the program to Grant MacEwan College in 1996. Today, this college offers a diploma program and a post-diploma baccalaureate program ranging from 2.5 years for the diploma program and an additional year for the post-diploma, if completed full-time. • In Saskatchewan, the program was transferred in 1972 to the Saskatchewan Institute of Applied Science and Technology and was housed there until 1996 when it was integrated into a four- year Nursing Education Program of Saskatchewan in partnership with the University of Saskatchewan. Students graduated with a Bachelor of Science in Nursing degree, but they could exit after three years, undertake additional eight weeks of clinical practice in psychiatric setting and obtain a Diploma in Psychiatric Nursing. Today, one institution offers a diploma program and a post- diploma baccalaureate program ranging from 2.5 years for the diploma program and an additional 2-2.5 years for the part-time post-diploma. • The Manitoba program moved to Brandon University, and in 1986, a post-diploma degree program was established for a Bachelor of Science in Mental Health. A diploma program was also offered at the Centre for Psychiatric Nursing Education at the Brandon Mental Health Centre. However, in 1995, the Manitoba government accepted the position that nurses should have a degree to practice and psychiatric nursing education was located at Brandon University. Since 2000, Brandon University has offered all four years of the degree program in Winnipeg as well as in Brandon (Pringle et al., 2004). Today, Brandon University continue to offers the baccalaureate and post-diploma program and, since 2011, also offers a Master in Psychiatric Nursing program. The program offers streams in advanced clinical practice, administration, and education.

Regulated Nursing in Canada: The Landscape in 2021 45 Today, registered psychiatric nurses must complete a program from one of the eight psychiatric nursing education programs in Canada approved by the psychiatric nursing regulatory bodies in Manitoba, Saskatchewan, Alberta, and British Columbia. The psychiatric nursing regulatory bodies collaborate to set common standards for the education programs and jointly establish minimum accepted educational requirements for registered psychiatric nursing (Registered Psychiatric Nurse Regulators of Canada, 2019b). Psychiatric nursing education prepares graduates to practice in the contexts of illness prevention, mental health promotion, and rehabilitation and recovery. Graduates are prepared to apply general nursing and psychiatric nursing knowledge to work with clients who have complex psychosocial, mental health, addiction, neurodevelopmental, and physical needs (Registered Psychiatric Nurse Regulators of Canada, 2014a). General nursing knowledge is part of the psychiatric nursing curriculum, but the primary emphasis is highly developed skills and knowledge in mental health and addictions and advanced therapeutic relationships and communication (Registered Psychiatric Nurse Regulators of Canada, 2015a). The psychiatric nursing education curriculum includes, at a minimum, the biological or physical sciences or both; the behavioural or social sciences or both; the humanities, and courses in ethics and research (Registered Psychiatric Nurse Regulators of Canada, 2014a). The psychiatric nursing education program must include, at a minimum, 775 clinical hours in psychiatric nursing and 225 hours in general medical surgical nursing. Currently, entry-to-practice education is a diploma or baccalaureate degree, but the Registered Psychiatric Nurse Regulators of Canada foresees that a baccalaureate in psychiatric nursing will be the minimum requirement for entry to practice in the future (Registered Psychiatric Nurse Regulators of Canada, 2015a).

REGISTERED NURSE EDUCATION Education for registered nurses has evolved a great deal over the last century. In 1874, St. Catharines’ General and Marine Hospital in Ontario established the first hospital training school for nurses in Canada. Following this, hospitals across the country introduced their own schools of nursing. Students learned by providing care to patients in hospital with limited coordination of classroom and clinical teaching, long hours, night duty without supervisors, and numerous housekeeping chores (Kozier, 2014; Baumgart & Larsen, 1992). Over the years this apprenticeship model changed progressively based on the development of the health care system, patient care needs, and nurses’ knowledge base.

In 1919, the University of British Columbia established the first baccalaureate nursing program in Canada, followed by the McGill School of Graduate Nurses and University of Toronto in 1920. The first baccalaureate program in French

46 was developed by Institut Marguerite d’Youville in 1938. The 1950s saw the greatest expansion of university schools of nursing. Students enrolled in the university for one year of non-nursing courses then moved to a hospital-based model for practical experience. A fifth year at the university completed what was labelled a sandwich program. The first integrated nursing degree program started at the University of Toronto in 1942, where university nursing faculty had control over education in the university and teaching of nursing practice within the hospitals (Kozier, 2014). In the 1960s, a limited number of community college nursing education programs began to appear, offering diploma preparation and, by the 1970s, most of the hospital programs had moved into community colleges (Baumgart & Larsen, 1992). During this time, students could enter a college nursing program to obtain their nursing diploma, or a university nursing program to obtain their baccalaureate degree. College programs were normally shorter in length than university programs.

In the 1990s, a national shift in registered nurse education took place as provinces and territories moved towards a baccalaureate nursing degree as the mandatory requirement for entry into practice (Table 5). Higher educational preparation was argued to provide the critical thinking skills necessary to make independent patient care decisions and manage complex care scenarios (Boblin et al., 2008; Tanner, 2006). The one exception was Quebec where a diploma from an approved program continues to be accepted for entry into practice. Over time, stand alone diploma programs were discontinued outside of Quebec, and community college programs were asked to collaborate with university programs. How this collaboration took place varied across the country. Some provinces/territories had a bottom-up approach which simply promoted collaborative practices between colleges and universities, others placed education programs completely with universities, while the remaining provinces/territories took a top-down approach by mandating collaboration between colleges and universities (Kozier, 2014). Since this shift started only in the late 1990s, both diploma-prepared and baccalaureate-prepared registered nurses currently practise in Canada.

Today, baccalaureate nursing degrees are offered by universities, community colleges, and polytechnic institutes with the majority of programs offered in universities. In some provinces and territories, programs in community colleges continue to be offered in a collaborative partnership with university schools leading to a baccalaureate degree in nursing. However, in some provinces, colleges have been granted degree-granting privileges by legislation and offer a baccalaureate education in nursing independently (Kozier, 2014). In Quebec, colleges continue to provide a Diploma of College Studies in Nursing which allows nurses to practise as a general care nurse or to study at a university to earn a bachelor’s degree in two years (Ordre des infirmières et infirmiers du Québec, 2019c).

Regulated Nursing in Canada: The Landscape in 2021 47 Table 5. Year baccalaureate entry-level requirements implemented for registered nurses

Province/territory Year Atlantic provinces 1998 Saskatchewan 2000 Ontario 2005 British Columbia 2006 Alberta, Northwest Territories and Nunavut 2010 Manitoba 2012 Quebec Continues to offer diploma programs Yukon No entry-level education programs

Source: Canadian Nurses Association. (2019c).

Entry-level programs for registered nurses are based on a broad knowledge of biological, social, and physical sciences, as well as the liberal arts and humanities. There is a strong focus on critical thinking, health prevention and promotion, health maintenance, and health restoration (Kozier, 2011). Program length and number of clinical hours required to qualify remain diverse across Canada, with minimum clinical hours not being mandated by the regulator in some provinces and territories (Garrett & MacPhee, 2014). Also, the degree of simulated experience permitted to be considered as clinical practice has no current national standard, making the level of preparatory experience across Canada quite diverse (Garrett & MacPhee, 2014).

In direct entry programs, students are admitted directly into the program and graduate with a degree in 4 years. Programs also exist for students with a previous degree (not in nursing), or credits toward a degree (usually about half the requirements of the degree) in which the nursing content has been reconfigured so that students can graduate with a nursing degree in approximately 2 years. These are called second entry, compressed, advanced, or accelerated programs. In Quebec, the Diploma of College Studies in Nursing usually lasts three years with some institutions offering a fast track program to those who already have a Diploma. The baccalaureate degree in Quebec is usually three years if students do not already have a Diploma and allows nurses to practice as clinical nurses or as nursing consultants (Ordre des infirmières et infirmiers du Québec, 2019c).

NURSE PRACTITIONER EDUCATION In 1967, the first Canadian education program for nurse practitioners was initiated and offered at Dalhousie University until 1997. Its emphasis was on preparation for primary health-care practice in remote communities (Martin-Misener et al., 1999). Programs at McMaster University and in other provinces followed quickly thereafter (Haines, 1993; Herbert & Little, 1983). These early programs were housed in universities and offered post-diploma or post-baccalaureate preparation

48 for what was often referred to as the expanded role of the nurse and family practice nursing (Hanrahan, Way, Housser,& Aplin, 2001; Chambers et al., 1974; Jones & Parker, 1974). In the mid-1980s, funding for nurse practitioner education programs in all but remote areas virtually disappeared once the physician shortage was resolved (Spitzer, 1984). In the 1990s, however, cutbacks in medical residency positions along with a health-care reform agenda brought renewed government interest in the nurse practitioner role and funding for education programs in some provinces (DiCenso et al., 2007).

In 1995, the Council of Ontario University Programs in Nursing approved its primary health care nurse practitioner program (Andrusyszyn, 1999; Cragg et al., 2003). Funding for the program was provided by the Ontario Ministry of Health and Long-Term Care and came with a requirement that the program be offered at the post-baccalaureate level. The curriculum was developed and offered jointly by nine schools in French and English, distance and on-site, and in post-baccalaureate certificate and post-baccalaureate programs. Soon after this program was established, other programs followed suit in almost every province with some initiated at the post-diploma level, some at the post-baccalaureate level, and others at the master’s level (Rutherford and Rutherford Consulting Group Inc., 2005). The first acute care nurse practitioner education programs were started during the 1980s and 1990s and, in contrast to primary health care nurse practitioner programs, all began at the graduate level (Dunn & Nicklin, 1995; Haddad, 1992). The first acute care nurse practitioner program designed to educate neonatal nurse practitioners, was offered at McMaster University in 1986. Today, neonatal/neonatology nurse practitioners complete a post-master’s diploma in the provinces where the role is recognized (Kilpatrick et al., 2010).

There has been diversity in the educational preparation of nurse practitioners with program length varying from several months to two years and, as noted above, program level ranging from post-diploma certificates to a master’s degree to a post-master’s degree (Kaasalainen et al., 2010; Martin-Misener et al., 2010). In the last two decades with regulation and legislation, there is greater consistency, as well as a move to master’s preparation (Canadian Association of Schools of Nursing, 2012). National and provincial regulatory frameworks have also been established to guide the certification, registration, standards, and core competencies for nurse practitioners’ practice (Canadian Association of Schools of Nursing, 2012). Course commonalities across nurse practitioner programs in Canada include advanced level courses in health assessment, pathophysiology, and therapeutic management of actual or potential health problems (Canadian Nurse Practitioner Initiative, 2006b). There is a lack of standardization in the number of clinical placement hours required, and a lack of consistency in the core non-nurse practitioner courses required in master’s programs as this is often determined by the individual program (Canadian Association of Schools of Nursing, 2012).

Regulated Nursing in Canada: The Landscape in 2021 49 GRADUATE EDUCATION The growth of university nursing programs encouraged the development of graduate studies in nursing with the first master’s program established at the University of Western Ontario in 1959. Master’s programs may be course-based or a combination of course work and thesis research. Programs generally take one to two years to complete. Nursing degrees most frequently granted are master of nursing (MN), master of science in nursing (MScN), and master of nursing science (MNSc).

Core components of a master’s curriculum are designed to enable students to synthesize research, theory, and practice at an advanced level. In addition to the core components, the focus of master’s study may include the preparation of nurses with advanced leadership skills in clinical practice (e.g. nurse practitioner, clinical nurse specialists), nursing education (academic and health care institutions), administration (institutional, community, and educational), health policy, and nursing research (Canadian Association of Schools of Nursing, 2011). Additionally, many nurses supplement their practice through master’s programs outside of nursing (e.g., education, aging and health, business administration).

DOCTORAL EDUCATION The need for doctoral programs in nursing was first discussed in Canada in 1975 (Baker et al., 2012), and this need continued to grow as baccalaureate programs and advanced practice roles increased. The first doctoral program began at the University of Alberta in January 1991 and was closely followed by the University of British Columbia in September 1991. Two more programs were established in 1993, one at the University of Toronto, and a joint program between McGill University and the Université de Montréal, which has since become two separate and independent programs.

Today, there are 18 doctor of philosophy (PhD) nursing programs available in most provinces. The University of Toronto has introduced a doctor of nursing (DN) program starting in 2021 that focuses on developing skills in translating research into practice, applying research knowledge in decision-making, and developing and implementing clinical innovations (University of Toronto, 2020b). While Canadian nursing doctoral programs have different objectives, they share a focus on providing a research-intensive program and offering a small number of core courses (Baker et al., 2012). Nurses with doctoral and post-doctoral education are needed in both academic and practice settings for advanced clinical practice, administration, education, and research.

50 Regulated Nursing in Canada: The Landscape in 2021 51 52 Scope of Practice

Scope of practice encompasses the roles, functions, and activities regulated nurses are legally authorized, educated, and competent to perform. It also refers to the knowledge of regulated nurses and the comprehensive application of that knowledge. In turn, scope of practice forms the foundation on which competencies and practice standards are developed, informs curriculum content of entry-level programs, assists with staffing decisions in practice settings, and informs health-care workforce planning. Expanded scopes of practice occur when nurses take on a wider range of tasks in the practice setting that would be considered outside their traditional scopes of practice (Nelson et al., 2014). Full scope denotes nurses practicing the full range of skills for which they have been trained and are competent to perform. Alternatively, working to optimal scope means achieving the most effective configuration of professional roles, determined by other health-care professionals’ relative competencies (Nelson et al., 2014).

Figure 3. Scope of practice boundaries (Adapted from Canadian Nurses Association, 2015)

Client, patient, community, population needs

Individual Nurse

Environment or setting ACTAL SCOE OF ACTCE

Professional standards and guidelines

Professional regulation

Legislation

OTE LTS OF SCOE OF ACTCE

Regulated Nursing in Canada: The Landscape in 2021 53 As noted in Figure 3, (page 53) scope of practice encompasses the outer limits of scope of practice and the actual scope of practice. The overall scope and boundaries of practice for each regulated nurses’ profession sets the outer limits of practice. The overall scope is defined in provincial and territorial legislation and regulations then complemented by entry-level competencies, standards of practice, guidelines, policy positions, and ethical standards from jurisdictional nursing regulatory bodies. Generally, the scope of practice defined in legislation is broad enough to allow for flexibility in interpretation as well as for changes in practice, diversity of contexts, evolving trends, and new models of care. Major modifications in practice require changes in the legislation and consultation with the members of the profession, government, the public, employers, and other health professionals (College of Registered Nurses of Nova Scotia, 2015). The actual scope of practice of individual nurses is more focused and is shaped by the needs and health goals of clients, the practice setting or context of practice, requirements of the employer as described in employer policies, and the level of the individual nurse’s competence to perform the activities necessary (Canadian Nurses Association, 2015; College and Association of Registered Nurses of Alberta, 2011a; College of Licensed Practical Nurses of Manitoba, College of Registered Nurses of Manitoba and College of Registered Psychiatric Nurses of Manitoba, 2010). Each of these areas is described in more detail below.

OUTER LIMITS OF SCOPE OF PRACTICE Legislation and Profession Regulation As noted earlier, legislation found in provincial and territorial statutes provides the legislative framework for nursing practice and outlines how the nursing profession is regulated (Canadian Nurses Association, 2007). The legislated scope of practice statement encompasses all activities in which nurses can engage in, but refers to the profession as a whole, rather than what any individual nurse can do. The practice statement may further define specific roles and responsibilities of nurses (College and Association of Registered Nurses of Alberta, 2011a; College of Nurses of Ontario, 2018a). Legislation may be specific to nursing, such as a Nursing Act, or encompassed within umbrella legislation that applies to several different health-care providers, such as a Health Professions Act (Canadian Nurses Association, 2007).

A Nursing Act is developed to regulate each of the different designations of nurses, such as Saskatchewan’s Licensed Practical Nurses Act, Registered Nurses Act (including registered nurses and nurse practitioners), and Registered Psychiatric Nurses Act. Each Act contains a scope of practice statement and, depending on the province or territory, the activities which regulated nurses are authorized to do. The Act establishes the mandate of the

54 regulatory body in that province or territory and includes definitions around classes of nursing registration and qualifications for becoming a regulated nurse.

A Regulated Health Professions Act is developed to regulate health professions using a model that allows for non-exclusive, overlapping scopes of practice. In this model, no single profession has exclusive ownership of a specific skill or health service and different professions may provide the same health services. A regulation, such as the Nurses (Registered Psychiatric) Regulation in British Columbia, is then developed specific to each profession. Under a Regulated Health Professions Act and/or regulation, the scope of practice of the profession is established through the scope of practice statement and, depending on the province, the restricted activities, controlled acts or reserved acts authorized for the profession (see below). Provinces with Regulated Health Professions Acts include British Columbia, Alberta, Ontario, and Prince Edward Island. Manitoba recently passed legislation for a Regulated Health Professions Act, however not all categories of regulated nurses are currently governed by this legislation.

• Restricted activities are high risk activities performed as part of providing a health service that requires specific competencies and skills to be carried out safely. Restricted activities are not linked to any particular health profession and a number of regulated health practitioners may perform a particular restricted activity. Restricted activities authorized for each profession are then described under the profession’s regulation, such as the Registered Nurses Profession Regulation (College and Association of Registered Nurses of Alberta, 2019b). Three provinces, British Columbia, Alberta and Prince Edward Island, identify restricted activities for each category of regulated nurses. • Controlled acts are activities that are considered to be potentially harmful if they are performed by unqualified persons. Regulated nurses are authorized to perform specific controlled acts appropriate to their profession’s scope of practice. Having the authority to perform a procedure does not necessarily mean that the individual is competent or that it is appropriate for the individual to perform the procedure (College of Nurses of Ontario, 2018a). Ontario identifies controlled acts for each category of regulated nurse. • Reserved acts are clinical activities, done in the course of providing health care, that present significant risk of harm to the public when performed incompetently. These acts are limited to certain regulated health professions, members who are qualified and competent to do them, and the circumstances in which a person may or may not perform those acts. Each reserved act can be performed by more than one category of health-care provider. Authorizing mechanisms are a way by which health-care providers obtain the authority to perform a reserved act (College of

Regulated Nursing in Canada: The Landscape in 2021 55 Registered Nurses of Manitoba, 2019a; Legislative Assembly of Manitoba, 2009). Currently, a list of reserved acts is identified for registered nurses and nurse practitioners in Manitoba under the new Regulated Health Professional Act. The Act does not yet apply to licensed practical nurses and registered psychiatric nurses. Quebec also identifies reserved and authorized acts. Regulation The Nursing Act, Regulated Health Professions Act, and/or the regulations by provincial and territorial governments mandate and delegate to nursing regulatory bodies (by statute) the power to regulate themselves and ensure the profession remains accountable to the public and governments. This includes the powers, duties, and responsibilities of the regulatory body, its members and their employers, as well as the definition of practice, regulation of the profession, and authority for members to use a title, or any variation or abbreviation of that title. The Regulations also addresses the registration requirements, standards for education and practice, code of ethics, and continuing competence. Regulatory bodies have the authority to decide which activities are within the scope of practice of the profession within the defined scope of practice statement in their Regulations (College of Registered Nurses of Nova Scotia, 2015).

Professional Standards and Guidelines In addition to jurisdictional legislation and regulation, other documents, including standards of practice and codes of ethics, are developed by provincial and territorial regulatory bodies to establish and maintain regulated nurses’ scope of practice as health-care delivery and nursing knowledge advances, and entry-level competencies required for initial registration change (Canadian Nurses Association, 2015). Depending on the province or territory, professional standards, standards of practice, practice standards, or practice expectations provide an overall framework for the practice of regulated nurses in the jurisdiction and articulate their legal and professional obligations which apply to all practice settings, domains of practice, and roles regardless of an individual nurses’ educational preparation or professional experience. The standards set a minimal level of practice to which regulated nurses are held accountable by their respective regulatory body. Under each standard of practice there are a number of representative indicators that help determine how to meet the standard of practice (College of Registered Psychiatric Nurses of Manitoba, 2010). In situations where standards are breached, a complaint process exists in each of the regulatory bodies wherein an objective investigation occurs, and appropriate consequences are determined. Professional conduct review is an integral element in profession-led regulation.

Regulatory bodies may also develop documents (practice guidelines, practice directives, or resources) outlining the activities regulated nurses are

56 authorized to perform and advise on exemptions to the regulations and specify regulations. For example, the College of Nurses of Ontario, which is under a controlled acts model, has a document (College of Nurses of Ontario, 2020a) to outline the authorizing mechanisms which provide registered nurses the authority to implement treatment plans and protocols. Other regulators have developed decision trees or decision-making frameworks as analytical tools to assist nurses, employers, and other stakeholders in determining whether or not an activity or action is within the scope of practice of a regulated nurse, or which nursing designation to match with client needs.

ACTUAL SCOPE OF PRACTICE Environment or Setting Context Nursing practice among regulated nurses may differ in the same environment based on context, educational preparation, competence, and focus (College of Licensed Practical Nurses of Manitoba, College of Registered Nurses of Manitoba and College of Registered Psychiatric Nurses of Manitoba, 2010). The environmental or setting context is where the nursing practice takes place and the consideration of environment includes availability of and access to resources, including support for nurses, policies, procedures, medical directives, and protocols to guide decision-making and practice (College of Nurses of Ontario, 2018a).

Environment factors also include consultation resources and the stability/ predictability of the environment. Nurses consult with one another when a situation demands nursing expertise that is beyond their competence. The amount of consultation required is determined by the complexity of client care needs and the nurse’s competence. The practice setting influences the availability and accessibility of these consultation resources as an important aspect of efficient consultation is providing nurses with the time and resources needed to consult as often as is necessary to meet client needs. Nurses practicing in settings with less access to other members of the health care team and less stable environments should have a higher level of competence and may need access to other resources, other health care professionals, equipment, technology and policies (College of Licensed Practical Nurses of Manitoba, College of Registered Nurses of Manitoba and College of Registered Psychiatric Nurses of Manitoba, 2020; College of Nurses of Ontario, 2018a).

Individual Nurse It is important for regulated nurses to be aware of the limits of their individual competence and practice as well as ensuring they understand other regulated

Regulated Nursing in Canada: The Landscape in 2021 57 nurses’ roles and levels of competence. Common ground exists between the scopes of practice of regulated nurses with respect to both their unique and shared competencies. Mutual understanding is needed in these areas to promote role clarity and ensure that each provider is utilized properly. Even within autonomous practice, consultation and collaboration are key components of the practice of every nurse. It is imperative that nurses know the limits of their practice and that they consult with others when that limit has been reached (College of Licensed Practical Nurses of Manitoba, College of Registered Nurses of Manitoba and College of Registered Psychiatric Nurses of Manitoba, 2010).

The scope of practice of an individual nurse is also shaped by individual experience and opportunities as well as ongoing professional development and formal education. Educational programs provide the knowledge, skill, judgment, and attributes required by each nursing designation to meet entry-level competencies. While all nursing designations share some of the same theoretical preparation and basic competencies, there are fundamental differences between them (College of Licensed Practical Nurses of Manitoba, College of Registered Nurses of Manitoba and College of Registered Psychiatric Nurses of Manitoba, 2010). For example, although registered nurses and registered psychiatric nurses both enter their professions with undergraduate preparation, the context of practice is different in terms of their primary focus. Registered nurses and licensed practical nurses study from the same body of nursing knowledge, however registered nurses study for a longer period of time, allowing for greater foundational knowledge in clinical practice, decision-making, critical thinking, leadership, research utilization and resource management. As a result of these differences, the level of autonomous practice of registered nurses differs from licensed practical nurses (College of Nurses of Ontario, 2018a).

Irrespective of basic educational preparation, all nurses must continually enhance their knowledge and competence through ongoing learning, education, experience, and participation in quality assurance activities as required by regulators in each jurisdiction (College of Licensed Practical Nurses of Manitoba, College of Registered Nurses of Manitoba and College of Registered Psychiatric Nurses of Manitoba, 2010). Though the activities that are within the scope of practice are covered in undergraduate education, the graduate may not be proficient in implementing all the skills/competencies upon graduation. Further learning is necessary and must be obtained through additional education or practice before implementation. The employer is expected to help fill this gap and provide the education, policy, and practice support (College of Registered Nurses of Nova Scotia, 2015).

58 The Client, Patient, Community and/or Population Overall client care requirements are influenced by the complexity of care needed, the predictability of outcomes, and the risks of negative outcomes in response to the care provided. Complexity refers to the degree to which a client’s condition and care requirements are identifiable and established based on all of the variables influencing that client’s current health status, and the variability of their condition or care requirements. Predictability refers to the extent to which a client’s outcomes and future care requirements can be anticipated. Risk of negative outcomes refers to the likelihood that a client will experience a negative outcome as a result of their health condition or in response to treatment (College of Nurses of Ontario, 2018a).

When making decisions about nursing practice and utilization of the different nursing designations, a number of regulatory bodies have developed decision-making tools using the three client factors described above to create a representation of the client that can be placed on a continuum. Most often these tools are designed to differentiate between the practice of licensed practical nurses and registered nurses. The continuum goes from less complex, more predictable, and lower risk for negative outcomes, to highly complex, unpredictable and higher risk for negative outcomes (College of Nurses of Ontario, 2018a). Based on this tool, licensed practical nurses have greater autonomy when caring for a client with fewer complexities. As client care needs start to become more complex, unstable, and unpredictable, there is an increasing need for consultation and collaboration with registered nurses. Registered nurses have greater autonomy when caring for clients whose conditions are highly complex and unpredictable with a high risk of negative outcomes. Registered nurses and registered psychiatric nurses can autonomously meet the nursing needs of clients, within the context of their practice, regardless of the complexity of the client’s condition (College of Licensed Practical Nurses of Manitoba, College of Registered Nurses of Manitoba and College of Registered Psychiatric Nurses of Manitoba, 2010).

Determining the appropriate designation of regulated nurse is complex. The scope of practice provides a broad starting point but does not provide a definitive formula as there is overlap in the scope of practice of each of the regulated nursing designations. Several factors must be taken into consideration with the nurse, the client, and the environment combined, ultimately guiding decisions about which nursing designation is appropriate (Lankshear & Martin, 2019). In some situations, all regulated nursing designations may have the knowledge, skill, judgment, and personal attributes to provide care. In other situations, the knowledge, skill, judgment, and personal attributes required may be unique to one nursing designation. Members of the four nursing designations are not interchangeable because

Regulated Nursing in Canada: The Landscape in 2021 59 of differences in the basic education, scope of practice, knowledge, skills, judgment, and personal attributes of each (College of Licensed Practical Nurses of Manitoba, College of Registered Nurses of Manitoba and College of Registered Psychiatric Nurses of Manitoba, 2020). The following section will provide an overview of the requisite skills and abilities, entry-level competencies and standards of practice for each designation.

LICENSED PRACTICAL NURSES Appendix B presents an overview of the nursing legislation, regulations, scope of practice definitions, entry-level competencies, and standards of practice of licensed practical nurses by province and territory across Canada. In the Yukon, Northwest Territories and Nunavut, licenced practical nurses are regulated by the government, each through a Licensed Practical Nurses Act. In the Yukon, practicing licensed practical nurses follow the standards of practice, code of ethics, practice statements, and competency profile of the College of Licensed Practical Nurses of Alberta. The Northwest Territories and Nunavut do not provide this information on their website.

Requisite Skills and Abilities Identifying requisite skills and abilities provides the public and practitioners with information about the nature of the activities and general demands of entry-level education and practice which licensed practical nurses and students require to successfully enter and continue within the profession (with or without accommodation). They are listed under seven categories: cognitive, communication, interpersonal, behavioural, sensory perceptual, physical, and environment. The list is not exhaustive, but rather provides a snapshot of the nature and types of activities specific to the entry-level practice of the licensed practical nurse (Canadian Council for Practical Nurse Regulators, 2013a).

Cognitive - ability to perform skills which demonstrate thinking capacity;

Behavioural - ability to conduct oneself in a professional manner;

Communication - ability to express and receive written, verbal, and non-verbal information in a respectful and professional manner;

Interpersonal - ability to create positive relationships;

Physical - ability to perform and have control over actions, such as bending, reaching and walking, to provide safe client care and to actively participate in educational activities;

60 Sensory perceptual - ability to accurately perceive with each of the four senses (sight, hearing, smell, touch) to provide safe care and participate in nursing activities;

Environmental - ability to function in the presence of commonly encountered and unavoidable environmental factors, such as distraction, noise, unpredictable behaviour of others, chemicals, noxious odours, and disease agents (Canadian Council for Practical Nurse Regulators, 2013a).

Entry-Level Competencies In 2013, the Canadian Council for Practical Nurse Regulators published the Entry-to-Practice Competencies for Licensed Practical Nurses. In response to the changing health care environment, these competencies were updated in 2019 and describe the knowledge, skills, judgment, and attitudes required of beginning practitioners to provide safe, competent, and ethical nursing care (Canadian Council for Practical Nurse Regulators, 2019). The 76 entry-level competencies are organized in five categories:

1. Professional practice: adhere to practice standards and an ethical framework; responsible and accountable for safe, competent, and ethical nursing practice; demonstrate professional conduct; focus on personal and professional growth; and utilize knowledge, critical thinking, critical inquiry, and research to build an evidence-informed practice. 2. Ethical practice: use ethical frameworks when making professional judgments and practice decisions; engage in critical thinking and critical inquiry to inform decision-making; and use self-reflection to understand the impact of personal values, beliefs, and assumptions in the provision of care. 3. Legal practice: adhere to applicable provincial/territorial and federal legislation and regulations, professional standards, and employer policies that direct practice; and engage in professional regulation by enhancing their competence, promoting safe practice, and maintaining their fitness to practice; and recognize that safe nursing practice includes knowledge of relevant laws and legal boundaries. 4. Foundations of practice: use critical thinking, reflection, and evidence integration to assess clients, plan care, implement interventions, and evaluate outcomes and processes. Their foundational knowledge includes nursing theory, health sciences, humanities, pharmacology, and ethics. 5. Collaborative practice: work collaboratively with clients and other members of the health care team guided by shared values and accountability, a common purpose or care outcome, mutual respect, and effective communication (Canadian Council for Practical Nurse Regulators, 2019).

Regulated Nursing in Canada: The Landscape in 2021 61 Upon review of websites for provincial regulators and/or territorial governments, eight had posted the Canadian Council for Practical Nurse Regulators (2013) or Canadian Council for Practical Nurse Regulators (2019) entry-level competencies. The Northwest Territories and Nunavut do not identify entry-level competencies on the government websites. Some provinces have adapted the document slightly for their jurisdiction. The College of Nurses of Ontario (2019b) identifies 79 competencies within the same five categories. The College of Licensed Practical Nurses of Manitoba has organized its entry-level competencies into six categories with similar but slightly different titles (people-centred care, collaborative care, reflective practice, knowledge-based practice, safe and ethical care, and leadership).

Registration Requirements Individuals who decide to pursue careers as licensed practical nurses must meet certain formal requirements for registration with the regulatory body. In general, the following criteria are common across the jurisdictional regulatory bodies:

• Successfully meet the regulatory authority’s education (approved diploma programs) and language requirements, • Demonstrate ability to meet the entry-level competencies, • Pass an approved registration examination (see below), • Demonstrate evidence of good character, including possessing the moral and ethical judgment expected of a licensed practical nurse, • Demonstrate fitness to practise as a licensed practical nurse, • Demonstrate the cognitive, behavioural, communication, interpersonal, and physical skills and abilities to engage in the practice of a licensed practical nurse, • Submit a satisfactory criminal record review, and • Hold professional liability protection (Canadian Council for Practical Nurse Regulators, 2013a).

Currently, licensed practical nurse applicants are required to successfully complete the Canadian Practical Nurse Registration Examination in regulatory jurisdictions (except for Quebec which uses its own exam), in order to obtain registration. Yardstick Assessment Strategies Inc. currently provides the Canadian Practical Nurse Registration Examination, and has been selected as the vendor to develop, implement, and deliver a new exam using computer- adaptive testing starting in 2022 in eight jurisdictions in Canada: Yukon, Alberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador (Canadian Council for Practical Nurse Regulators, 2018). The British Columbia College of Nursing Professionals and the College of Nurses of Ontario are partnering with the National Council of

62 State Boards of Nursing to develop a new exam (Regulatory Exam - Practical Nurse (REx-PN)) for practical nurses that will also be introduced in 2022 (British Columbia College of Nursing Professionals, 2020a; College of Nurses of Ontario, 2020b). Five provinces (Alberta, Manitoba, Ontario, New Brunswick and Nova Scotia) also require the successful completion of a jurisprudence examination or module to measure an individual nurse’s awareness of provincial and regulatory policies and any provincial and federal laws that would relate to nursing practice.

Standards of Practice The Standards of Practice for Licensed Practical Nurses (LPNs) in Canada (Canadian Council for Practical Nurse Regulators, 2013b) provides a national framework for the practice of licensed practical nurses in Canada. In conjunction with the Code of Ethics for Licensed Practical Nurses (Canadian Council for Practical Nurse Regulators, 2013c), the standards describe the elements of quality practice and facilitate mobility through inter-jurisdictional mutual understanding and agreement of expectations and requirements for practice (Canadian Council for Practical Nurse Regulators, 2013b). The four broad standards of practice are:

1. Professional accountability and responsibility: accountable for their practice and responsible for ensuring that practice and conduct meet both the standards of the profession and legislative requirements; 2. Knowledge-based practice: possess knowledge obtained through practical nurse preparation and continuous learning relevant to professional practice; 3. Service to the public and self-regulation: practise nursing in collaboration with clients and other members of the health-care team to provide and improve health-care services in the best interests of the public; and, 4. Ethical practice: uphold, promote, and adhere to the values and beliefs as described in the Canadian Council for Practical Nurse Regulators Code of Ethics (Canadian Council for Practical Nurse Regulators, 2013b). Seven of the websites of the provincial regulators and/or territorial governments list the Standards of Practice for Licensed Practical Nurses (LPNs) in Canada (Canadian Council for Practical Nurse Regulators, 2013b). The British Columbia College of Nursing Professionals have adapted the standards slightly within their document on professional standards. The College of Licensed Practical Nurses of Manitoba uses similar standards but have separated knowledge-based practice into knowledge and application of knowledge and also added three additional standards: self-regulation, continuing competency, and professional leadership. The College of Nurses of Ontario added three

Regulated Nursing in Canada: The Landscape in 2021 63 similar standards including continuing competency, professional leadership, and relationships. The Northwest Territories and Nunavut do not identify standards for practice on the government websites.

Five provinces (Alberta, Saskatchewan, Quebec, New Brunswick, and Newfoundland and Labrador) also provide a competency profile on their websites. The Yukon refers to the competency profile from Alberta. The purpose of the Competency Profile is to articulate the knowledge, skills, attitudes, behaviors, and judgment required of the profession of practical nursing in that province. The profile also guides curriculum development and supports employers to understand the full scope of practice for determining the practice of licensed practical nurses in their care settings. The competency profile includes skills included in the entry-level education as well as post- basic skills (College of Licensed Practical Nurses of Alberta, 2020; College of Licensed Practical Nurses of Newfoundland and Labrador, 2019; Saskatchewan Association of Licensed Practical Nurses, 2016).

REGISTERED PSYCHIATRIC NURSES Appendix C presents an overview of the nursing legislation, regulations, scope of practice definitions, entry-level competencies, and standards of practice for registered psychiatric nurses in the four Western provinces and the Yukon. In the Yukon, registered psychiatric nurses are regulated by the government under the Health Professions Act.

Requisite Skills and Abilities Similar to the other designations of regulated nurses, the requisite skills and abilities required to practise as a registered psychiatric nurse are organized into the same seven categories with examples specific to the entry-level practice of registered psychiatric nurses: cognitive, communication, interpersonal, behavioural, sensory perceptual, physical, and environment. The College of Registered Psychiatric Nurses of Manitoba includes an eighth category, ethical and legal. Only the College of Registered Psychiatric Nurses of Manitoba and the British Columbia College of Nursing Professionals provide documents on their websites identifying the requisite skills and abilities.

Entry-Level Competencies In 2013, the Registered Psychiatric Nurse Regulators of Canada, consisting of the provinces of British Columbia, Alberta, Saskatchewan, and Manitoba, collaborated to develop national entry-level competencies for registered psychiatric nurses in Canada (Registered Psychiatric Nurse Regulators of Canada, 2014a). The regulators in each of the four provinces now provide these

64 competencies on their websites. There are seven competency categories, each with key competencies and enabling competencies, and all of equal weight. These include:

1. Therapeutic relationships and therapeutic use of self: the foundational instrument that registered psychiatric nurses use to establish therapeutic relationships with clients to deliver care and psychosocial interventions. 2. Body of knowledge and application: (practice is comprised of foundational nursing knowledge and specialized psychiatric nursing knowledge) integrate general nursing knowledge and knowledge from the sciences, humanities, research, ethics, spirituality, and relational practice with specialized knowledge drawn from the fields of psychiatry and mental health; use critical inquiry and application of a decision-making process in providing psychiatric nursing care, which includes evidence-informed knowledge and application of body of knowledge. 3. Collaborative practice: work in collaboration with team members, families, and other stakeholders to deliver comprehensive psychiatric nursing care in order to achieve the client’s health goals. 4. Advocacy: use expertise and influence to support clients to advance their health and well-being on an individual and community level. 5. Quality care and client safety: collaborate in developing, implementing, and evaluating policies, procedures, and activities that promote quality care and client safety. 6. Health promotion: use expertise to promote the physical and mental health of clients to prevent disease, illness, and injury. 7. Ethical, professional, and legal responsibilities: practice within legal requirements; demonstrate professionalism; and uphold professional codes of ethics, standards of practice, bylaws, and policies. (Registered Psychiatric Nurse Regulators of Canada, 2014a). Registration Requirements Those wishing to become registered psychiatric nurses must meet certain formal requirements for registration with the regulatory body. In general, the following criteria are common across the jurisdictional regulatory bodies:

• Graduate from an approved psychiatric nursing education program (diploma and baccalaureate), • Pass the Registered Psychiatric Nurses of Canada Examination, • Demonstrate that they possess the good character expected of a registered psychiatric nurse, • Provide evidence of English language proficiency, • Provide evidence of fitness to practise, • Pass a criminal record check, and • Hold professional liability protection (BCCNP, n.d.).

Regulated Nursing in Canada: The Landscape in 2021 65 All graduates of the eight education programs for registered psychiatric nurses must successfully complete the national registration examination, the Registered Psychiatric Nurses of Canada Examination (exam testing partner is Yardstick Assessment Strategies), to qualify for registration as a registered psychiatric nurse (Registered Psychiatric Nurse Regulators of Canada, 2014b).

Standards of Practice The registered psychiatric nursing regulators in Alberta, British Columbia, Manitoba and Saskatchewan worked together to develop and validate the Standards of Psychiatric Nursing Practice 2019 (British Columbia College of Nursing Professionals, College of Registered Psychiatric Nurses of Alberta, College of Registered Psychiatric Nurses of Manitoba and Registered Psychiatric Nurses Association of Saskatchewan, 2019). These standards set out the minimum acceptable level of performance required of a registered psychiatric nurse and apply to all practice settings, domains, and roles, regardless of an individual nurse’s educational preparation or professional experience. The five broad standards of practice are:

1. Therapeutic relationships: establishes collaborative professional, interpersonal, and therapeutic relationships with clients. 2. Competent, evidence-informed practice: continually acquires and integrates evidence-informed knowledge and builds on psychiatric nursing education and lifelong learning. 3. Professional responsibility and accountability: accountable and responsible for safe, competent, and ethical psychiatric nursing practice that meets the standards of the profession and legislated requirements. 4. Leadership and collaboration in quality psychiatric nursing practice: enhances the safety, quality, and effectiveness of psychiatric nursing practice through leadership and collaboration. 5. Professional ethical practice: understands, upholds, and incorporates the profession’s Code of Ethics into their professional practice (British Columbia College of Nursing Professionals, College of Registered Psychiatric Nurses of Alberta, College of Registered Psychiatric Nurses of Manitoba and Registered Psychiatric Nurses Association of Saskatchewan, 2019).

Three of the provinces have posted the 2019 standards on their websites. The College of Registered Psychiatric Nurses of Alberta has an older version of the standards that does not include standard #4, leadership and collaboration. The Yukon Registered Psychiatric Nurses Regulation states that registered psychiatric nurses practicing in the Yukon shall follow the standards of practice of the College of Registered Psychiatric Nurses of Manitoba.

66 REGISTERED NURSES Appendix D presents an overview of the nursing legislation, regulations, scope of practice definitions, entry-level competencies, and standards of practice for registered nurses by province and territory across Canada. In each province and territory, registered nurses are regulated by a jurisdictional nursing regulatory body.

Requisite Skills and Abilities Similar to the other designations of regulated nurses, the requisite skills and abilities required to practise as a registered nurse are organized into the same seven categories with examples specific to the entry-level practice of registered nurses. The categories include cognitive, communication, interpersonal, behavioural, sensory perceptual, physical, and environment. The majority of the provinces/territories provides documents listing the requisite skills and abilities organized in these seven categories, with the exception of the College of Registered Nurses of Manitoba which identifies five categories (cognitive, behavioural, communication, physical, sensory).

Entry-Level Competencies In 2017, the Canadian Council of Registered Nurse Regulators initiated the revisions of the Entry-Level Competencies of Registered Nurses in Canada. This initiative was led by a working group comprised of 11 jurisdictions representing registered nurse regulators in Canada. A total of 101 competencies are grouped thematically under nine roles. Integration of all nine roles enables the entry-level registered nurse to provide safe, competent, ethical, compassionate, and evidence-informed nursing care in any practice setting. Some concepts are relevant to multiple roles. The roles include:

1. Clinician: provide safe, competent, ethical, compassionate, and evidence-informed care across the lifespan in response to client needs; and integrate knowledge, skills, judgment and professional values from nursing and other diverse sources into their practice. 2. Professional: commit to the health and well-being of clients; uphold the profession’s practice standards and ethics and are accountable to the public and the profession; demonstrate accountability, accepts responsibility, and seeks assistance as necessary for decisions and actions within the legislated scope of practice. 3. Communicator: use a variety of strategies and relevant technologies to create and maintain professional relationships, share information, and foster therapeutic environments. 4. Collaborator: play an integral role in the health-care team partnership.

Regulated Nursing in Canada: The Landscape in 2021 67 5. Coordinator: coordinate point-of-care health service delivery with clients, the health-care team, and other sectors to ensure continuous, safe care. 6. Leader: influence and inspire others to achieve optimal health outcomes for all. 7. Advocate: support clients to voice their needs to achieve optimal health outcomes and support clients who cannot advocate for themselves. 8. Educator: identify learning needs with clients and apply a broad range of educational strategies towards achieving optimal health outcomes. 9. Scholar: demonstrate a lifelong commitment to excellence in practice through critical inquiry, continuous learning, application of evidence to practice, and support of research activities (College and Association of Registered Nurses of Alberta, 2019c; College of Nurses of Ontario, 2019c; College of Registered Nurses of Manitoba, 2019b; College of Registered Nurses of Prince Edward Island, 2019a; Nova Scotia College of Nursing, 2013; Nurses Association of New Brunswick, 2019b; Registered Nurses Association of the Northwest Territories and Nunavut, 2019a; Saskatchewan Registered Nurses Association, 2019b).

Registration Requirements Those wishing to become a registered nurse must meet certain formal requirements for registration with the regulatory body. In general, the following criteria are common across the jurisdictional regulatory bodies:

• Graduate from an approved nursing education program (baccalaureate in all provinces except Quebec which requires a diploma), • Pass the NCLEX-RN; except in Quebec which requires exam from Ordre des infirmières et infirmiers du Québec, • Demonstrate that they possess the good character expected of an registered nurse, • Provide evidence of English language proficiency, • Provide evidence of fitness to practise, • Pass a criminal record check, and • Hold professional liability protection.

Six provinces (British Columbia, Alberta, Ontario, New Brunswick, Nova Scotia, and Prince Edward Island) also require the successful completion of a jurisprudence examination or module.

68 Since January 2015, registered nurse applicants are required to successfully complete the National Council Licensure Examination for Registered Nurses (NCLEX-RN) in 10 of Canada’s regulatory jurisdictions to obtain registration. This exam is developed and administered by the National Council of State Boards of Nursing in the United States using computer-adaptive testing (Villeneuve, 2017). In the Yukon, the Yukon Registered Nurses Association processes applicants via endorsement from other Canadian provinces or territories. Applicants for registered nurse registration in Québec complete the Ordre des infirmières et infirmiers du Québec’s professional examination (Canadian Council of Registered Nurse Regulators, 2018b).

Standards of Practice Compared to the other designations of regulated nurses, the standards of practice for registered nurses are variable across Canada with no national framework identified. Some of the standards are similar while others vary with a range from four to nine standards. Several provinces also have separate practice guidelines (called standards in some provinces) which are not discussed here. Each standard is supported by indicators meant to illustrate how registered nurses will meet the standards. Indicators are meant to apply across a variety of settings, and may be further refined by the context of practice. Some provinces also illustrate how each standard is applied in four main areas of practice: clinical, education, administration, and research.

The following is a summary of the different broad standards in each of the provinces and territories:

1. Professional responsibility and accountability or professional responsibility: is responsible and accountable for their own practice and professional conduct • Listed in the standards in Yukon, Northwest Territories and Nunavut, British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Nova Scotia, Prince Edward Island, Newfoundland and Labrador. 2. Knowledge-based practice: continually acquires and applies knowledge, skills and judgement to provide competent, evidence- informed nursing care and service • Listed in the Standards in Yukon, Northwest Territories and Nunavut, British Columbia, Alberta, Saskatchewan, New Brunswick, Nova Scotia, and Newfoundland and Labrador. • The College of Registered Nurses of Prince Edward Island divided this into two standards, competent application of knowledge and unique body of knowledge • The College of Nurses of Ontario divided this into knowledge application and knowledge

Regulated Nursing in Canada: The Landscape in 2021 69 3. Client-centered care or client focused provision of service: provides nursing services and works with others to provide health-care services in the best interest of clients; contributes to and promotes measures that optimize positive client health outcomes at the individual, organizational, and system level • Listed in the standards in Yukon, Northwest Territories and Nunavut, British Columbia, Manitoba, New Brunswick, Nova Scotia, and Newfoundland and Labrador. • Service to the public is a similar standard listed by The College and Association of Registered Nurses of Alberta and the Saskatchewan Registered Nurses Association: duty to provide safe, competent, and ethical nursing care and service in the best interest of the public. 4. Ethical practice or ethics: understands, upholds, and promotes ethical standards; complies with the Code of Ethics • Listed in the standards in British Columbia, Alberta, Saskatchewan, Manitoba, and Ontario. 5. Professional relationships and leadership: establishes professional relationships and demonstrates leadership to deliver quality nursing and health-care services. • Listed in the standards in the Yukon, Northwest Territories and Nunavut, New Brunswick, Nova Scotia, and Newfoundland and Labrador. • The College of Nurses of Ontario divides the standard into therapeutic nurse-client relationships and professional relationships. • The College of Registered Nurses of Manitoba has three standards that overlap slightly with this standard: professional communication, collaborative care, and practice environments. 6. Self regulation: fulfills the professional obligations related to self- regulation; is accountable to regulate themselves in accordance with their legislated and individual scope of practice. • Listed in the standards in Alberta, Saskatchewan, and Nova Scotia. 7. Continuing competence: demonstrates responsibility for maintaining competence, fitness to practise, and integrating new knowledge and skills in own area of practice. • Listed in the standards in Ontario, and Prince Edward Island. 8. Advocacy: demonstrates advocacy for clients by responding to their needs in a way that supports, protects, and safeguards the client’s rights and interests. • Listed in the standards in Prince Edward Island.

70 9. Follow-up to diagnosis and test results: when ordering a diagnostic test or making a referral, a nurse must have a system in place to review the results and remain responsible for any follow-up care required • Listed in the standards in Manitoba. 10. Client records: must appropriately document the nursing care provided • Listed in the standards in Manitoba.

REGISTERED NURSE PRESCRIBING Several provinces and territories have implemented or are considering implementing some level of registered nurse prescribing to help improve access to health services. The registered nurse prescriber is a registered nurse with an expanded scope of practice that enables them to prescribe medications and devices and order relevant screening or diagnostic tests within their specific area of prescribing competence and practice. Registered nurse prescribers must complete additional education and meet additional registration requirements (Nova Scotia College of Nursing, 2019b).

British Columbia Nurse with certified practice (RN-C). Registered nurses who have successfully completed a certified practice course and evaluation are permitted to apply for an RN-C license. Decision support tools set out the activities and establish the parameters for this expanded scope of registered nurse practice (British Columbia College of Nursing Professionals, 2020b). This allows registered nurses to diagnose some diseases and disorders and carry out some restricted activities autonomously (as set out in decision support tools) that would otherwise require an order ( e.g., administering, compounding, or dispensing Schedule 1 medications) (British Columbia College of Nursing Professionals, 2020b). Today, there are three categories of certified practice:

1. Remote nursing practice (work in communities where there may not be a resident physician or nurse practitioner): Registered nurses with this certification can diagnose and treat minor acute illness and carry out all activities included in reproductive health certification. 2. Reproductive health: Certified registered nurses can diagnose and treat sexually transmitted infections and/or provide contraceptive management. 3. RN first call (commonly seen in small acute care hospitals, diagnostic and treatment centres and other settings): Registered nurses with this certification can diagnose and treat minor acute illness.

Regulated Nursing in Canada: The Landscape in 2021 71 Alberta A registered nurse who is authorized to prescribe designation in Alberta refers to registered nurses who are authorized to prescribe Schedule 1 drugs in accordance with the requirements and standards of practice outlined by the regulator (College and Association of Registered Nurses of Alberta, 2019d). A registered nurse must apply to the registrar for authority to prescribe Schedule 1 drugs (except controlled drugs and substances) and order diagnostic tests within a specific clinical practice area. A registered nurse who is authorized to prescribe must a) conduct a comprehensive health assessment appropriate to the specific clinical practice area; b) interpret and apply the clinical support tool for the clinical practice area when ordering diagnostic tests and prescribing; c) order and interpret diagnostic tests as indicated in the specific clinical support tool; and d) consult or transfer the client care to other health-care professionals if the ordering diagnostic tests and prescribing decision is beyond their scope, knowledge, or competence (College and Association of Registered Nurses of Alberta, 2019d).

The following assumptions form the basis for the competencies for a registered nurse who is authorized to prescribe:

1. Their practice is grounded in the values, knowledge, and theoretical foundations of professional registered nursing practice. 2. Their competencies build and expand upon the entry-level competencies required of a registered nurse. 3. Before being authorized, they have successfully completed an approved nursing program for prescribing and the ordering of diagnostic tests. 4. Before being authorized, they have completed a minimum of 3,000 hours of registered nurse clinical practice, 750 hours of which are within the specific clinical practice area where they will order diagnostic tests and prescribe. 5. They practise in collaboration with other health-care providers. 6. They only prescribe medications and order diagnostic tests as described in the clinical support tool (College and Association of Registered Nurses of Alberta, 2019d).

Saskatchewan Registered nurses with additional authorized practice (RN(AAP)) was created for registered nurses working in Saskatchewan’s northern communities (Saskatchewan Registered Nurses Association, 2018b). To qualify for this registration, nurses must complete the three approved courses through Saskatchewan Polytechnic Continuing Education – Health Assessment, Clinical Drug Therapy, and a course with 200 hours of clinical practice education experience (Saskatchewan Registered Nurses Association, 2020). The scope

72 of practice is broader than that of other registered nurses, since it includes the diagnosis and treatment of individuals with limited common medical disorders as identified in the clinical decision tools. A RN(AAP) may a) order, perform, receive, and interpret reports of screening and diagnostic tests that are designated in the bylaws; b) prescribe and dispense drugs in accordance with the bylaws; c) perform minor surgical and invasive procedures that are designated in the bylaws; and d) diagnose and treat common medical disorders (Saskatchewan Registered Nurses Association, 2018b). In addition to the registered nurse standards and competencies, the RN(AAP) must practice according to the current Saskatchewan Registered Nurses Association Standards and Competencies for the Registered Nurse with Additional Authorized Practice (Saskatchewan Registered Nurses Association, 2018b).

The role of the RN(AAP) is not to replace the services provided by nurse practitioners. Nurse practitioners possesses a larger breadth and depth of knowledge, skill, and judgment regarding common medical disorders within their specialty. Unlike nurse practitioners, the practice of the RN(AAP) is restricted to limited common medical disorders that are addressed in the clinical decision tools.

Manitoba Registered nurse (authorized prescriber) or RN(AP), in Manitoba, is a registered nurse with a certificate of practice that includes the notationauthorized prescriber for an approved patient population. RN(AP)s are able to prescribe certain medications and order or receive diagnostic tests in these areas (College of Registered Nurses of Manitoba, 2020). The registered nurse must successfully complete an approved course of instruction and obtain approval from the registrar to practice as an RN(AP) for the patient populations in any of the following areas: a) travel health; b) reproductive health, sexually transmitted infections, and blood borne pathogens; and/or c) diabetes health (College of Registered Nurses of Manitoba, 2020).

The role of the RN(AP) is not to replace the services provided by nurse practitioners who have a broader scope of practice and can independently prescribe drugs, order and manage screening and diagnostic tests, or set or cast a fracture of a bone or dislocation of a joint. In contrast, an RN(AP) has a specific scope of practice, provides care within the three practice areas mentioned above, and can only prescribe certain medications or order and receive diagnostic tests in these areas (College of Registered Nurses of Manitoba, 2020).

Regulated Nursing in Canada: The Landscape in 2021 73 Nova Scotia In Nova Scotia, a provincial committee was formed in 2017 and is leading the exploration of improved access to health-care services by enabling registered nurses with specialized education and skills to prescribe medications within their specific area of expertise, practice setting, and client population (Nova Scotia College of Nursing, 2019b).

Ontario In 2017, the Ontario government changed legislation to permit registered nurses to prescribe medication and communicate diagnoses for the purpose of prescribing medications to treat non-complex health conditions. The College of Nurses of Ontario is currently working towards developing the regulatory framework that will enable this practice advancement (College of Nurses of Ontario, 2020c).

Quebec In 2016, introduction of the first cohort of registered nurses with a prescribing designation was issued by the Ordre des infirmières et des infirmiers du Québec (Government of Quebec, 2016). Under the Regulation respecting certain professional activities which may be exercised by a nurse, nurses may prescribe in the areas of wound care, public health (sexual health, smoking cessation, perinatal vitamins, treatment of pediculosis), and certain common health issues (e.g., nausea and vomiting in pregnant women, fungal infections in babies and nursing mothers) (Government of Quebec, 2016; Ordre des infirmières et infirmiers du Québec, 2019d). In 2018-2019, 11% of registered nurses were prescribers in Quebec (n=8332) (Ordre des infirmières et infirmiers du Québec, 2019e).

NURSE PRACTITIONERS Appendix E presents an overview of the nursing legislation, regulations, scope of practice definitions, entry-level competencies, and standards of practice for nurse practitioners by province and territory across Canada. In each province and territory, nurse practitioners are regulated by a jurisdictional regulatory nursing body.

Entry-level competencies The entry-level competencies for nurse practitioners were developed by the Canadian Council of Registered Nurse Regulators as part of a national analysis conducted in 2014/2015 of three streams of nurse practitioner practice: Family/ All Ages (Primary care), Adult, and Child/Pediatric (Canadian Council of

74 Registered Nurse Regulators, 2016). The identified competencies are based on a review of Canadian regulatory documents (e.g., provincial/ territorial competencies, standards, etc.), with relevant research evidence and were validated through a practice analysis survey. They build and expand upon the competencies required of a registered nurse and address the knowledge, skills, and abilities that are included in the nurse practitioners’ legislated scope of practice (Canadian Council of Registered Nurse Regulators, 2016). These competencies are now used in each of the provinces and territories and are organized into four competency categories:

1. Client Care: further divided into six sub-competency categories, which reflect the importance of the clinical dimension of the nurse practitioner professional role. a. Client relationship building and communication: uses appropriate communication strategies to create a safe and therapeutic environment for client care. b. Assessment: integrates an evidence-informed knowledge base with advanced assessment skills to obtain the necessary information to identify client diagnoses, strengths, and needs. c. Diagnosis: engages in the diagnostic process and develops differential diagnoses through identification, analysis, and interpretation of findings from a variety of sources. d. Management: on the basis of assessment and diagnosis, formulates the most appropriate plan of care for the client, implementing evidence-informed therapeutic interventions in partnership with the client to optimize health. e. Collaboration, consultation and referral: identifies when collaboration, consultation, and referral are necessary for safe, competent, and comprehensive client care. f. Health promotion: uses evidence and collaborates with community partners and other health-care providers to optimize the health of individuals, families, communities, and populations. 2. Quality improvement and research: uses evidence-informed practice, seeks to optimize client care and health service delivery, and participates in research. 3. Leadership: demonstrates leadership by using the nurse practitioner role to improve client care and facilitate system change. 4. Education: integrates formal and informal education into practice. This includes but is not limited to educating self, clients, the community, and members of the health-care team, as well as continuing competency as a practitioner (Canadian Council of Registered Nurse Regulators, 2016).

Regulated Nursing in Canada: The Landscape in 2021 75 Registration Requirements Those wishing to become nurse practitioners must meet certain formal requirements for registration with the regulatory body. In general, the following criteria are common across the jurisdictional regulatory bodies:

• Graduate from an approved nursing education program (master’s required), • Demonstrate that they possess the good character expected of an registered nurse, • Provide evidence of English language proficiency, • Provide evidence of fitness to practise, • Pass a criminal record check, and • Hold professional liability protection.

Nurse practitioner applicants are required to successfully complete either an approved adult, pediatric, or family/all ages exam in their regulatory jurisdictions in order to obtain registration (Spence, Agnew, & Fahey-Walsh, 2015). Across Canada, several registration exams are recognized by regulatory bodies:

• Adult exams include the American Nurses Credentialing Centre examination in adult-gerontology primary care, the American Academy of Nurse Practitioners examination in adult gerontology primary care, the American Academy of Nurse Practitioners (AANP) examination in adult care or the American Nurses Credentialing Centre exam in adult care (2005-2014). Pediatric exams include Pediatric Nursing Certification Board nurse practitioner certification exam and the American Nurses Credentialing Centre exam in pediatrics (2005-2014). • Family/all ages exams include the Canadian Nurse Practitioner Examination in the care of family/all ages, the American Nurses Credentialing Centre examination in family care, or the American Academy of Nurse Practitioners examination in family care. • Quebec has separate exams for nurse practitioners specializing in neonatology, adult care, pediatric care, primary care, and mental health (Ordre des infirmières et infirmiers du Québec, 2019a).

Currently, British Columbia and Quebec also require a practical examination (i.e., objective structured clinical examination or OSCE), while a jurisprudence examination/module is a registration requirement in Ontario and Nova Scotia. Four jurisdictions (Northwest Territories and Nunavut, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador) require the completion of either an approved course on prescribing controlled drugs and substances theory or evidence that this was taught in the nurse practitioner program. Some

76 jurisdictions also register nurse practitioners in neonatology, either as a distinct stream or as part of the pediatric/child stream. Neonatal/Neonatology nurse practitioners complete a post-master’s diploma in the provinces where the role is recognized (Kilpatrick et al., 2010). In the Yukon, the Yukon Registered Nurses Association processes applicants via endorsement from other Canadian provinces or territories. Nurse practitioners are normally registered in one specialty, category, or stream and need to report a change in client population to their jurisdictional regulator if changing streams.

Standards of Practice Across Canada, the standards for nurse practitioners are similar, but they differ in range from four to seven standards. Three provinces/territories (Northwest Territories, British Columbia, and Alberta) identify the same standards of practice for registered nurses and nurse practitioners while Newfoundland and Labrador use one document to identify four standards applicable to registered nurses and nurse practitioners, with an additional three standards applicable to nurse practitioners. Each standard is supported by indicators to illustrate how the nurse practitioner will meet the standards. Indicators are meant to apply across a variety of settings, and they may be further refined by the context of practice. The Canadian Nurse Practitioner Core Competency Framework (Canadian Nurses Association, 2010b) is a companion document of each of the standards for practice for nurse practitioners. Lastly, some provinces also illustrate how each standard is applied in four main areas of practice: clinical, education, administration, and research.

1. Professional responsibility and accountability: responsible and accountable for their own practice and professional conduct. • Listed in the standards in Yukon, Northwest Territories and Nunavut, British Columbia, Alberta, Saskatchewan, New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador. 2. Knowledge-based practice or use of knowledge, skill and judgment or knowledge/knowledge application: knowledgeable of advanced practice clinical judgment, knowledge, skills and clinical reasoning. • Listed in the standards in Northwest Territories and Nunavut, British Columbia, Alberta, Saskatchewan, Manitoba, and Newfoundland and Labrador. 3. Consultation and collaboration or consultation, referral, and transfer or collaboration, consultation, and referral: identify when collaboration, consultation, and referral are necessary for safe, competent, and comprehensive client care. Consult and collaborate with other health-care providers as appropriate to ensure that the overall health-care needs of clients are met. • Listed in the standards in Manitoba, Ontario, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador

Regulated Nursing in Canada: The Landscape in 2021 77 4. Health assessment and diagnosis: integrates a broad knowledge base and critical appraisal in determining and communicating the diagnosis and the client’s needs; integrates an evidence-informed knowledge base with advanced assessment skills to obtain the information necessary for identifying client diagnoses, strengths, and needs. • Listed in the standards in Yukon, New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador. • The College of Nurses of Ontario lists health assessment as one standard and diagnosis as another standard. • The College of Registered Nurses of Manitoba lists ordering screening and diagnostic tests. 5. Client-centered care or client-focused provision of service: contributes to and promotes measures that optimize positive client health outcomes at the individual, organizational and system level. • Listed in the standards in Yukon, Northwest Territories and Nunavut, British Columbia, and Newfoundland and Labrador. • Service to the public is a similar standard listed by The College and Association of Registered Nurses of Alberta and the Saskatchewan Registered Nurses Association: the nurse has a duty to provide safe, competent, and ethical nursing care and service in the best interest of the public. • Client care management is a similar standard listed by the Nova Scotia College of Nursing and College of Registered Nurses of Newfoundland and Labrador: client care management is guided by the best available evidence and the determinants of health. 6. Therapeutic management: utilizes advanced knowledge and judgement in applying pharmacological and non-pharmacological interventions. • Listed in the standards in Yukon, Saskatchewan, Ontario, New Brunswick, and Prince Edward Island • The College of Registered Nurses of Manitoba lists prescribing drugs and devices 7. Ethical practice: understands, upholds, and promotes ethical standards; complies with the Code of Ethics • Listed in the standards in British Columbia, Alberta, and Saskatchewan 8. Self regulation: fulfills the professional obligations related to self- regulation; is accountable to regulate themselves in accordance with her/his legislated and individual scope of practice. • Listed in the standards in Alberta, and Saskatchewan

78 9. Professional relationships and leadership or leadership and advocacy: establishes professional relationships and demonstrates leadership to deliver quality nursing and health-care services. • Listed in the standards in Northwest Territories and Nunavut, Nova Scotia, and Newfoundland and Labrador 10. Health promotion and prevention of illness and injury: promotes health and reduces the risk of complications, illness and injury for clients while contributing to the sustainability of the health-care system. • Listed in the standards in Yukon, New Brunswick, and Prince Edward Island 11. Conflict of interest: recognize and ethically manage actual, potential, and perceived conflicts of interest. • Listed in the standards in Ontario 12. Discontinuing the nurse practitioner-client relationship: the primary obligation is to provide safe and ethical nursing services to clients. Under provincial law, nurses may only discontinue necessary professional services if the client requests discontinuation, alternative or replacement services are arranged, or the client is given reasonable opportunity to arrange alternative or replacement services. • Listed in the standards in Ontario

Regulated Nursing in Canada: The Landscape in 2021 79 80 Unregulated Care Providers

Over the past three decades, provinces and territories have seen the introduction of a growing number of unregulated care providers providing some form of health service to patients in various contexts. The term unregulated is used as they normally have no legally defined scope of practice and are neither registered nor licensed by a regulatory body (Canadian Nurses Association, 2009). Unregulated care providers commonly assist patients with various activities of daily living and provide delegated nursing services under the supervision of regulated nurses in either institutional settings, such as nursing homes or hospitals, or in private homes in the community (Health Professions Regulatory Advisory Council, 2005; Lum, Sladek, & Ying, 2010). The title of these roles varies by province and territory (Table 6).

Table 6. Examples of Titles for Unregulated Care Providers by Province/Territory Province/Territory Examples of Titles North West Territories Personal support worker Yukon Health-care assistant Nunavut Personal support worker British Columbia Health-care assistant, care aides, life skills workers, psychiatric workers Alberta Health-care aide Saskatchewan Continuing care assistant Manitoba Health-care aide Ontario Personal support worker Quebec Home care assistant New Brunswick Personal support workers, personal care attendant Nova Scotia Continuing care assistant, personal care worker, home support worker Prince Edward Island Resident care worker, home support worker Newfoundland and Personal care attendant, home support worker Labrador

Regulated Nursing in Canada: The Landscape in 2021 81 Initially, the unregulated care provider role provided only supportive assistance as orderlies and porters (Canadian Nurses Association, 2005). However, with nursing shortages and economic pressures, the role has evolved with the work being dependent on care settings and the role description provided by specific employers (Canadian Nurses Association, 2005). Today, unregulated care providers provide care to patients who require personal assistance with activities of daily living. These activities include support for feeding, bathing, grooming, dressing, lifts and transfers, menu and meal planning, meal preparation, transportation or accompanying patients, shopping, and light housekeeping (Canadian Nurses Association, 2005; Knopp‐Sihota et al., 2015; Ontario Personal Support Workers Association, 2016; Suter et al., 2014; Zeytinoglu et al., 2014). They also provide additional care or tasks, as delegated by a regulated nurse, when they can be performed safely and within provincial/ territorial legislation. Supervision is required when performing a delegated task and regulated nurses must ensure that unregulated care providers have the basic competencies and knowledge base to safely conduct the delegated task.

Educational requirements, entry-level requirements, employment settings, scope of employment, and job descriptions differ across the country and from sector to sector (Canadian Nurses Association, 2005; Keefe et al., 2011). In the past, unregulated care providers received on-the-job training, but today they are prepared in short programs (about six months in duration) in high schools, private training organizations, community colleges, and other settings. The programs include training in personal care and support for seniors and other patients/residents in short-term hospital stays or long-term care. Education programmes are predominantly offered by public and private institutions, including online programs (Kelly & Bourgeault, 2015). However, on-site training continues to be provided by some employers and continuing education programs are also offered through school boards in some provinces, such as Ontario (Kelly & Bourgeault, 2015).

There is no national education standard for unregulated care providers to enter practice (Berta, Laporte, Deber, Baumann, & Gamble, 2013; Canadian Nurses Association, 2005). However, efforts have been made to standardise curricula in public colleges at a provincial and territorial level (Estabrooks et al., 2015; Association of Canadian Community Colleges, 2012). Provincial program curricula are offered in six provinces (British Columbia, Alberta, Ontario, Quebec, Newfoundland and Labrador, and Nova Scotia) while others use institutionally-approved curricula (Association of Canadian Community Colleges, 2012). These differences in education programs result in significant variation in the level of preparation offered across the country (Berta et al., 2013), creating differences in skills and competencies for graduates. For example, in a recent scoping review of unregulated care providers, Afzal and colleagues (2018) reported programs ranging from 485 hours in Alberta

82 to 850 hours in Nova Scotia. Currently, there is no mechanism to ensure curriculum standards are being followed due to lack of entry requirements (e.g., standardised examinations) in the workforce (Association of Canadian Community Colleges, 2012).

As they are unregulated and have various position titles, an accurate count is unknown at a national level. However, some information is available provincially. It was previously estimated that approximately 100,000 and 44,000 unregulated care providers provide care in Ontario and British Columbia, respectively (Berta et al., 2013; Foerster & Murtagh, 2013). While some provinces have developed registries of workers, registration varies from being mandatory to voluntary. For example, in 2010, British Columbia began mandatory registration of care aides in publicly funded nursing homes (British Columbia Care Aide and Community Health Worker Registry, 2013); while Nova Scotia began voluntary registration (Health Association Nova Scotia, 2012). In 2011, Alberta initiated an employer- implemented directory of care aides (Alberta Health Care Aide Directory, 2020) and, in 2012, Ontario established a pilot project for registration of personal support workers; however, the pilot project ended in March 2020 and the website indicates they are no longer accepting applications (Personal Support Worker Registry of Ontario, 2020).

The Canadian Support Workers Association is the national professional association for personal support workers, health care aides, personal care aides, personal care assistants, home support workers, and any other frontline health care workers within Canada (Canadian Support Workers Association., 2020). Saskatchewan, Newfoundland and Labrador, and Ontario have chapters that are members of the national association. However, membership appears to be voluntary. The Ontario Personal Support Worker Association has developed standards of practice to protect, not only the public in the delivery of the services provided by personal support workers, but also all vested stakeholders through the development of a defined scope of practice, standards of care, and a complaints process for all (Ontario Personal Support Worker Association, 2016). It is not clear how the standards are used in the province.

Regulated Nursing in Canada: The Landscape in 2021 83 84 Physician Assistants

Within the past two decades, physician assistants have been introduced in some provinces and territories, with approximately 700 physician assistants currently working in health care settings, primarily in Alberta, Manitoba, Ontario and New Brunswick (Canadian Association of Physician Assistants, 2020). Physician assistants are health care professionals educated in the medical model who work under the supervision of a registered physician in a variety of clinical team structures and settings, in accordance with the delegated medical act (Canadian Association of Physician Assistants, 2020; Wong & Farrally, 2013). While physician assistants provide a broad range of medical services, they are considered physician extenders and are not autonomous practitioners. A physician assistant’s scope of practice is physician delegated, and the medical services delegated to the physician assistant must be within the scope of the supervising physician. The relationship between the physician assistant and the supervising physician is the essential determinant of the role, within the context of their competencies, scope of practice, and provincial jurisdictions (Wong & Farrally, 2013). The role is then formally outlined in a practice contract or agreement between the supervising physician(s), the physician assistant, and, often, the facility where they work. Activities may include conducting patient interviews, histories, and physical examinations; performing selected diagnostic and therapeutic interventions or procedures; and counseling patients on preventive health care (Canadian Association of Physician Assistants, 2020).

The history of the physician assistant dates to 1984 when the Canadian Armed Forces adopted physician assistant as the role for senior medics, bringing it to the attention of physicians across Canada. In 1999, the Canadian Academy of Physician Assistants (now the Canadian Association of Physician Assistants) was formed, and in 2003, the Canadian Medical Association recognized the physician assistant as a unique health professional. The manner in which they practice today and how they are recognized and/or regulated varies across Canada.

• In Manitoba, physician assistants were regulated as clinical assistants between 1999 and 2009, and since 2009 have been regulated as physician assistants by the College of Physicians and Surgeons of Manitoba. The regulation provides for the registration of physician assistants on the physician assistant registry and the application for registration must include a supervision contract between a licensed doctor and physician assistant, which sets out the medical services to be provided, location, and type of supervision provided

Regulated Nursing in Canada: The Landscape in 2021 85 (Canadian Association of Physician Assistants, 2019). Manitoba is the only province/territory with specific legislation (the Medical Act) in place regarding physician assistants’ practice, allowing practice under the title of Physician Assistant (Wong & Farrally, 2013). • In New Brunswick, the Medical Act was amended in 2009 to allow physician assistants to be registered and licensed by the College of Physicians and Surgeons of New Brunswick. In 2010, a regulation established the terms of practice for physician assistants in the province and subsequently in 2014 they were awarded prescriptive rights (Canadian Association of Physician Assistants, 2019). • In Alberta, the Council of the College of Physicians and Surgeons of Alberta passed a bylaw in 2010 allowing physician assistants to operate under the responsibility of a regulated member. Physician assistants can register as non-members through the College of Physicians and Surgeons of Alberta, but they are not currently regulated (Canadian Association of Physician Assistants, 2019). • In Ontario, physician assistants were introduced in 2007 and work under delegated medical acts and direction of their supervising physician. Ontario has the highest number of practicing physician assistants in Canada, although they remain unregulated. • In 2019, the Nova Scotia Health Authority, with the support of the College of Physicians and Surgeons of Nova Scotia, announced the introduction of physician assistants in orthopaedic surgery as a pilot program (Canadian Association of Physician Assistants, 2019).

In Canada, there are four accredited physician assistant education programs that meet national standards of education, including a defined set of competencies that are outlined in the profession’s National Competency Profile (CanMEDS-PA). The competencies include medical expert, communicator, collaborator, leader, health advocate, scholar, and professional. The three civilian education programs are delivered in partnership with the faculties of medicine at Canadian universities. The program extends over 24 months and begins with classroom instruction in basic medical sciences. This is followed by physician-directed rotations with multidisciplinary teams. Students participate in clinical training in areas that can include trauma, anesthesia, general surgery, sports medicine, orthopedics, internal medicine, emergency medicine, pediatrics, and family medicine. Graduates are eligible to write the Physician Assistant Certification Council of Canada Physician Assistant Certification Exam entry to practice exam, and if successful, are awarded the Canadian Certified Physician Assistant designation (Canadian Association of Physician Assistants, 2019).

86 NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS A common misconception is that a nurse practitioner and a physician assistant are interchangeable where one can be replaced with the other (Little & Reichert, 2018). Previous reports have outlined the key differences between the two roles:

• Nurse practitioners are self regulated in all 13 provinces and territories. Physician assistants are primarily unregulated health care providers and are not directly accountable to a regulatory body (Little & Reichert, 2018; Wong & Farrally, 2013). • Nurse practitioners are autonomous professionals who practice under their own license and across a broad, regulated scope of practice. Physician assistants practice under the supervision of a registered physician(s) where their scope of practice is not determined by regulation but rather through a negotiated relationship with the supervising physician(s) (Little & Reichert, 2018; Wong & Farrally, 2013). • Nurse practitioners have a minimal master’s-level education combined with a minimum of two years of full-time experience practicing as a registered nurse with baccalaureate education, for a total of eight years. Physician assistants normally have one year of course work and one year of clinical experience in their training program (Little & Reichert, 2018; Wong & Farrally, 2013). • Nurse practitioners possess and demonstrate the competencies to autonomously diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals, and perform specific procedures within their legislated scope of practice. Physician assistants possess the knowledge, skills, and attributes to undertake delegated medical services (Little & Reichert, 2018; Wong & Farrally, 2013). • As a regulated health-care profession, nurse practitioners are autonomous professionals, legally responsible for their own practice and clinical judgment and are title protected. Physician assistants are not autonomous, independent providers (Little & Reichert, 2018; Wong & Farrally, 2013). • • Nurse practitioners’ scope of practice varies across jurisdictions, and is established through government regulations defining nursing practice and complemented by a regulatory set of standards and guidelines. Physician assistant’s scope of practice and their degree of autonomy in clinical decision making is negotiated with a supervising physician. The Canadian Association of Physician Assistants developed a Canadian Scope of Practice statement and Physician Assistant National Competency Profile (standard of practice) that are intended to be resources and are not part of a regulation (Little & Reichert, 2018; Wong & Farrally, 2013).

Regulated Nursing in Canada: The Landscape in 2021 87 • The educational model for nurse practitioners emphasizes knowledge acquisition and decision-making skills, population health and prevention, recognizes the social determinants of health, and stresses the analytical activities associated with primary care. The educational model for physician assistants prepares them to work as assistants to physicians rather than independent practitioners with less emphasis on analytical processes (Little & Reichert, 2018; Wong & Farrally, 2013).

88 Conclusion and Next Steps

This report is being published in February 2021 as Canada struggles with the second wave of the COVID-19 pandemic. The work of nurses has rarely been under such constant public discussion, as the country has rallied strongly around all our health care providers. But the pandemic has also revealed serious gaps across our health systems, which are forcing us to look at shortcomings we have papered over and patched for too long.

This expansive report should be an invaluable asset in exploring how nursing must be reconceptualized to help fill those gaps, as health-care systems across the country strive to determine how Canada’s 440,000 nurses, of every type, can most effectively be deployed. To meet the complex health policy challenges lying ahead, nurses and policy decision-makers must determine what conditions are needed to optimize scope, productivity, safety, and satisfaction in nursing practice.

There are numerous issues that might be traced to the traditional divisions this report illustrates in nursing education, regulation, scope of practice, and organizations. One such issue is how the best-educated generation of nurses in history is locked in roles and functions defined decades ago that underuse the intellectual capital of the entire nursing workforce. To be effective in 21st century health care, it may be that a more intraprofessional approach that overcomes the restrictions of our traditional hierarchy will ensure better care for patients and a better functioning health care system overall.

Another issue is whether the sheer number of nursing organizations (colleges, associations, and unions), with their commitment to different segments of the nursing workforce and individual interests and goals, create separation and block evolution in nursing care. Are they perpetuating outdated dynamics in the profession?

Other concerns — rigidly segregated education, jealously guarded delineation of scopes of practice, a lack of understanding of each others’ roles — may all be limiting nurses’ ability to give the quality of care patients need and deserve, and adding to the strain on our health-care systems. We hope this report, as a first step toward meaningful change, contributes clarity and a deeper understanding of all regulated nurses in Canada, encourages exploration of the structures and practices that facilitate the delivery of great care, and helps in the dismantling of barriers and traditions that hinder changing for the better.

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Regulated Nursing in Canada: The Landscape in 2021 109 110 Appendix A. Overview of Number of Institutions Offering Entry-Level Nursing Education Programs and Programs Available

Province or Licensed Practical Nurses Registered Psychiatric Registered Nurses Nurse Practitioners Territory Nurses

Yukon Currently no programs Currently no programs Currently no programs Currently no programs NWT/Nunavut Nunavut: Currently no programs - Nunavut: Currently no programs 1 institution offers a program: Bachelor of Science in Nursing (Arctic Nursing) NWT: Diploma in Practical Nursing at 1 college NWT: Currently no programs British Columbia 19 institutions offer programs 2 institutions offer programs with 12 institutions offer programs with the 3 institutions offer programs with the following available: with the following available: the following available: following available: Master of Nursing – Nurse Practitioner (MN-NP) Diploma in Practical Nursing Bachelor of Science in Psychiatric Baccalaureate Registered Nurse Program Nursing BSN Nursing Program Master of Science in Nursing – Family Nurse Practitioner Generic practical nursing (MScN-FNP) education programs: prepare Bachelor of Psychiatric Nursing Bachelor of Science in Nursing Program students to become LPNs Master of Nursing with Nurse Practitioner Option Diploma in Psychiatric Nursing Bachelor of Science Nursing – Advanced Access practical nursing Entry Note: all programs are Nurse Practitioner (Family) Master’s education programs: prepare Programs health-care assistants to become Advanced Standing Bachelor of Science in LPNs Nursing Northern Collaborative Baccalaureate Nursing Program

Appendix A - Regulated Nursing in Canada: The Landscape in 2021 111 Province or Licensed Practical Nurses Registered Psychiatric Registered Nurses Nurse Practitioners Territory Nurses

Alberta 9 institutions offer programs with 1 institution offers programs with 6 institutions offer programs with the 3 institutions offer programs with the following available: the following available: the following available: following available: Practical Nurse Diploma Program Psychiatric Nursing Diploma Master of Nursing: Advanced Practice Program Bachelor of Nursing Program The two-year program provides Post-Diploma Bachelor of Post-Master’s Diploma: Advanced Nursing Practice a minimum of 1650 instructional Psychiatric Nursing Bachelor of Science in Nursing Program Program hours including 750 hours of Bachelor of Science in Nursing (BScN) After Integrated Master of Nursing Nurse Practitioner Program theoretical instruction and 900 Degree Program hours of lab/clinical experience. Post-Master’s Nurse Practitioner Diploma Program BScN – Honors Program Family/All Ages BScN – After Degree Program Master of Nursing Clinical Program BScN Bilingual Program/Baccalaureat es sciences infirmieres (bilingue) Program Post-MN Program Bachelor of Science in Nursing (BScN) Adult Collaborative Program Master of Nursing Clinical Program Post-MN Program Neonatal Master of Nursing Clinical Program Post-MN Program Child (not currently admitting into this program) Master of Nursing Clinical Program Post-MN Program Saskatchewan 6 institutions offer programs with 1 institution offers programs with 2 institutions offer programs with the 2 institutions offer programs with the following available the following available: the following available: following available: Master of Nursing – Primary Health Care Nurse Diploma in Practical Nursing Psychiatric Nursing Diploma Collaborative Bachelor of Science in Nursing Practitioner Post-Diploma Bachelor of Bachelor of Science in Nursing (with a Post- Post-Graduate Nurse Practitioner Certificate Psychiatric Nursing Degree option) Master of Nursing (Nurse Practitioner)/Collaborative Nurse Practitioner Program Manitoba 3 institutions offer programs with 1 institution offers programs with 4 institutions offer programs with the 1 institution offers a program with the following available: the following available: the following available: following available: Masters of Nursing, Nurse Practitioner Program Practical Nursing Diploma Bachelor of Science in Psychiatric Bachelor of Nursing Program Program Nursing Nursing Baccalaureate Program Note: one institution is French Post Diploma Bachelor of Science only in Mental Health Master of Psychiatric Nursing

112 Province or Licensed Practical Nurses Registered Psychiatric Registered Nurses Nurse Practitioners Territory Nurses

Ontario 24 institutions offer programs - 15 institutions offer programs with the 10 institutions offer programs with the following available: with the following available: following available: Practical Nurse Diploma PHCNP (Masters) Generic Bachelor of Science in Nursing Program PHCNP Graduate Diploma (Post Masters) Collaborative Baccalaureate Nursing MN/PHCNP (Masters) Program PHCNP Certificate (Poster Masters) Collaborative Bachelor of Sciences in Master of Science Nursing/Diploma PHCNP Nursing (BScN) Program PHCNP – Global Health (Masters) Compressed Bachelor of Science in Nursing Program Post-Masters NP Diploma – Global Health (Post Masters) BScN Program Stream F – Basic Accelerated PHCNP – Adult (Masters) (2 years) Post-Masters Nurse Practitioner Diploma – Adult (Post BScN Scholar Practitioner Program (SPP) Masters) Four Year BNSc Program PHCNP – Paediatrics (Masters) Two Year BNSc Program Post-Masters Nurse Practitioner Diploma – Paediatrics (Post Masters) Programme de baccalaureate en sciences infirmieres Advanced Standing Program, Bachelor of Nursing Second-Entry Program, Bachelor of Nursing BScN (Honours) Collaborative Program (4 years) Quebec 13 institutions offer programs - 5 institutions offer programs with the 5 institutions offer programs with the following available: with the following available: following available: Master of Science (Applied) in Nursing Diploma of Vocational Studies Bachelor of Science (Nursing) Three Year (DVS): Health, Assistance, Program Masters in Nursing Sciences – Primary Care taken and Nursing (awarded by the simultaneously with the Specialized Graduate Diploma in Ministry of Education and Higher Bachelor of Science (Nursing) Four Year Nursing – Specialized Primary Care Practice Program Education) Master of Science in Nursing and a Specialized Studies (Health, Assistance and Nursing) Bachelor of Nursing Integrated Program Diploma Direct Entry Masters of Science in Nursing (accredited as a university degree that leads to entry-to-practice as a Registered Nurse) Bachelor of Science in Nursing, Basic Training Bachelor of Science in Nursing, DEC training in nursing

Appendix A - Regulated Nursing in Canada: The Landscape in 2021 113 Province or Licensed Practical Nurses Registered Psychiatric Registered Nurses Nurse Practitioners Territory Nurses

New Brunswick 3 institutions offer programs with - 2 institutions offer programs with the 2 institutions offer programs with the following available: the following available: following available: Master of Nursing – Nurse Practitioner Stream Diploma in Practical Nursing Bachelor of Nursing Master of Nursing Science – Nurse Practitioner (1 French and 2 English Nursing - Advanced Standing Program programs) Bachelor of Science in Nursing (regular students) Nova Scotia 1 institution offers programs with - 3 institutions offer programs with the 1 institution offers a program with the following available: the following available: following available: Master of Nursing Program in the following NP streams: Diploma in Practical Nursing Family, All Ages, Adults, Neonate Bachelor of Science of Nursing BScN 4-year Program Bachelor of Science of Nursing (Direct Entry & Advanced Standing) 2 Calendar Year BScN Program New Traditional 4 Year Educational Program New 2 Year Accelerated Educational Program Prince Edward 1 institution offers a program with - 1 institution offers programs with the 1 institution offers a program with the following available: Island the following available: following available: Master of Nursing – Nurse Practitioner Stream Diploma in Practical Nursing Bachelor of Science in Nursing (BScN) Program Accelerated BScN Program

Newfoundland 1 institution offers programs with - 1 institution offers programs with the 1 institution offers a program with the following available: and Labrador the following available: following available: Master of Nursing Nurse Practitioner (Adult and Family/ Diploma in Practical Nursing Bachelor of Nursing (Collaborative) Program All Ages) Bachelor of Nursing (Collaborative) Fast- Track Option

114 Appendix B. Licensed Practical Nurses

Overview of Legislation, Regulation, Scope of Practice, Designations, Additional Registration Requirements, Entry Level Competencies, and Standards of Practice by Province/Territory

Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements Yukon (Yukon Internationally Educated Health Professions) Yukon Licensed Yukon Licensed Practical Nurses Regulations states: - Licensed - Yukon Licensed Practical Nurses follow Practical Nurses Act Practical Nurse the Standards of Practice, the Code of Scope of practice 18.1 (LPN) Ethics, Practice Statements and (1) Registrants must practise practical nursing in accordance Competency Profile of the College of Yukon Licensed with standards of practice. Licensed Practical Nurses of Alberta Practical Nurses (2) A registrant must not practise practical nursing contrary Regulations to the limitations, conditions or restrictions applicable to the licence issued. (3) Registrants must restrict themselves to performing Standards of Practice for Licensed Practical Nurses in Canada Government of those activities that they are competent to perform and Yukon’s Professional that are appropriate to their area of practice and the 4 Standards: Licensing & procedure being performed. (1) Professional accountability and Regulatory responsibility Affairs Branch in Advanced or specialized practical nursing procedures 20.1 (2) Knowledge-based practice the Department of (1) The registrar may include in the licence of a registrant (3) Service to the public and self- Community Services who is a full registrant one or more special endorsements regulation is the regulatory that authorize the registrant to perform advanced or (4) Ethical practice authority for Licensed specialized practical nursing procedures, if the registrant (Canadian Council for Practical Nurse Practical Nurses in is otherwise eligible for the licence and provides to Regulators & College of Licensed Practical Yukon the registrar proof of (a) successfully completing an Nurses of Alberta, 2013) educational program of specific theory and practice; and (b) competence, to the satisfaction of the registrar, in the provision of the procedures. (2) The registrar may require the registrant to complete any special continuing professional education that the registrar considers appropriate, and the registrar may rescind the special endorsement if the registrant does not comply with the requirement. (3) Any special continuing professional education required under subsection (2) may, as directed by the registrar, be either in addition to or part of the continuing professional education. (4) A registrant who is enrolled in an advanced or specialized practice program approved by the registrar and who is receiving training in providing an advanced or specialized practical nursing procedure may perform that procedure under the supervision of a full registrant, or an authorized practitioner, who is authorized to perform the procedure and is available to provide assistance.

Appendix B - Regulated Nursing in Canada: The Landscape in 2021 115 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements Northwest Territories (NWT) (Government of the Northwest Territories) and Nunavut (Government of Nunavut) Licensed Practical Nunavut: - Licensed - Not provided on the websites Nurses Act (Nunavut) Practical Nurse (1) A licensed practical nurse who holds a license to (LPN) practise may engage in the practice of practical nursing for the purpose of (a) promoting, maintaining, and The Government restoring health; (b) preventing and alleviating illness, of Nunavut Health injury and disability; (c) assisting in prenatal care, Branch is the childbirth, and postnatal care; and (d) caring for the regulatory authority terminally ill and the dying. in Nunavut (2) The practice of practical nursing means the provision of practical nursing services (a) independently, for patients considered stable with predictable outcomes; and (b) Licensed Practical under the guidance or direction of a registered nurse, Nurses Act (NWT) nurse practitioner, medical practitioner or other health- care professional authorized to provide such guidance or direction, for patients considered unstable with The Office of the unpredictable outcomes. Registrar, Professional (3) Practical nursing services means the application Licensing, of practical nursing theory in the (a) assessment of Government of the patients; (b) collaboration in the development of a Northwest Territories, nursing plan of care for a patient; (c) implementation Department of of a nursing plan of care for a patient; and (d) ongoing Health and Social evaluation of a patient. Services is the (4) A licensed practical nurse may assist in administration, regulatory authority supervision, education, consultation, teaching, policy for nursing in the development and research with respect to any of the Northwest Territories matters referred to in subsections (1) or (3) .

116 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements British Columbia (British Columbia College of Nursing Professionals) Health Professions Practical nursing means the health profession in which a Restricted Activities Licensed - Entry-to-Practice Competencies for Licensed Act person provides the following services: Practical Nurse Practical Nurses (LPN) 76 entry-level competencies organized in 5 (a) Health care for the promotion, maintenance and Additional detail categories: Nurses (Licensed restoration of health, with a focus on stable or regarding limits and predictable states of health; (1) Professional Practice Practical) Regulation conditions is provided in (2) Legal Practice the Scope of Practice for (3) Ethical Practice Prevention, treatment, and palliation of illness (b) Licensed Practical Nurses (4) Foundations of Practice and injury, with a focus on stable or predictable (5) Collaborative Practice disorders and conditions primarily by (i) assessing (British Columbia College health status), (ii) planning, implementing, and of Nursing Professionals, (Canadian Council for Practical Nurse evaluation interventions, and (iii) coordinating 2020c) Regulators & British Columbia College of health services Nursing Professionals, 2013) (Nurses (Licensed Practical) Regulation, 2015) Professional Standards for Licensed Practical Nurses 4 Standards: (1) Responsibility and Accountability (2) Competency-Based Practice (3) Client-Focused Provision of Services (4) Ethical Practice (British Columbia College of Nursing Professionals, 2020d)

Appendix B - Regulated Nursing in Canada: The Landscape in 2021 117 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements Alberta (College of Licensed Practical Nurses of Alberta) Health Professions LPNs in Alberta practice autonomously and assume Restricted Activities Licensed Jurisprudence Entry-Level Competencies for Licensed Act full responsibility for their own practice. As trusted and Practical Nurse Examination Practical Nurses respected professional nurses, LPNs service individuals, (LPN) 76 entry-level competencies organized in 5 families, and groups, assessing their needs and providing Additional detail care and treatments as appropriate. categories: Licensed Practical regarding limits and (1) Professional Practice Nurses Profession conditions is provided in (2) Legal Practice Regulation the Competency Profile (3) Ethical Practice LPNs are accountable for their own nursing practice and as for Licensed Practical (4) Foundations of Practice any professional, are expected to seek assistance when the Nurses, Fifth Edition (5) Collaborative Practice needs within their practice go beyond their competence (Canadian College of Practical Nurse level. (College of Licensed Practical Nurses of Regulators, 2019) Alberta, 2020) Standards of Practice LPNs advocate for clients related to all areas of practice 4 Standards: including human, physical, and financial resources (1) Professional Accountability and necessary to provide safe, quality nursing care. LPNs work Responsibility collaboratively with clients, families, and the health-care (2) Knowledge-Based Practice team to ensure continuity of care and quality health service (3) Service to the Public and Self- delivery. Regulation (College of Licensed Practical Nurses of Alberta, 2020) (4) Ethical Practice (Canadian Council for Practical Nurse Regulators and College of Licensed Practical Nurses of Alberta, 2013) Standards of Practice for Licensed Practical Nurses on Restricted Activities and Advanced Practice (2020)

118 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements Saskatchewan (Saskatchewan Association of Licensed Practical Nurses) The Licensed “Practice as a licensed practical nurse” means to provide - Licensed Code of Ethics Entry-to-Practice Competencies for Licensed Practical Nurses Act services, within the education and training of licensed Practical Nurse course completion Practical Nurses practical nurses, for the purposes of providing care, (LPN) promoting health, and preventing illness. 76 entry-level competencies organized in 5 categories: (The Licensed Practical Nurses Act, 2000) (1) Professional Practice (2) Legal Practice (3) Ethical practice Saskatchewan Association of Licensed Practical Nurses (4) Foundations of Practice Competency Profile (5) Collaborative Practice Professional scope of practice consists of basic (Canadian Council for Practical Nurse competencies, additional competencies, and specialized Regulators & Saskatchewan Association of areas of LPN practice: Practice as a Licensed Practical Nurse Licensed Practical Nurses, 2013a) means to provide services within the education and training of licensed practical nurses, for the purpose of providing care, promoting health, and preventing illness. Standards of Practice for Licensed Practical Nurses in Canada (Saskatchewan Association of Licensed Practical Nurses, 2016) 4 Standards: (1) Professional Accountability and Responsibility (2) Knowledge-Based Practice (3) Service to the Public and Self- Regulation (4) Ethical Practice (Canadian Council for Practical Nurse Regulators & Saskatchewan Association of Licensed Practical Nurses, 2013b)

Appendix B - Regulated Nursing in Canada: The Landscape in 2021 119 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements Manitoba (College of Licensed Practical Nurses of Manitoba) The Licensed The provision of nursing services for the purpose of As part of the transition Licensed Education session Entry-Level Competencies for the Licensed Practical Nurses Act assessing and treating health conditions, promoting health, to the Regulated Health Practical Nurse on jurisprudence Practical Nurse in Manitoba preventing illness, and assisting individuals, families and Professions Act, the (LPN) groups to achieve an optimal state of health (The Licensed College will be required Entry-level competencies organized into 6 Practical Nurses Act, 2020) to make a submission domains: Licensed Practical (1) People-Centered Care Nurses Regulation to the Government of Manitoba outlining (a) Communication and Relational the reserved acts that Skills fall within the scope of (b) Respect, Dignity, and Human Regulated Health practice of Manitoba’s Rights Professions Act LPNs. Currently, LPNs (c) Partnership with the Client are governed by The (2) Collaborative Care Licensed Practical Nurses (3) Reflective Practice According to the Act. (a) Critical Thinking College’s website, (b) Evidence-Based Practice the Regulated Health (c) Nursing Process Professions Act (4) Knowledge-Based Practice does not yet apply (5) Safe and Ethical Care to LPNs, and the (a) Integrating Professional transition date is Responsibilities unknown. (b) Documentation and Reporting (c) Safe Practice Currently, LPNs (6) Leadership in Manitoba are (a) Principles of Effective Leadership governed by The (b) Clinical Leadership Licensed Practical (c) Health Promotion and Client Nurses Act and Education its Regulation until they are replaced by (College of Licensed Practical Nurses of the RHPA. Manitoba, 2016) Standards of Practice 4 Standards: (1) Knowledge (2) Application of Knowledge, Skills, and Judgement (3) Professional Service in the Public Interest (4) Ethical Practice (5) Self-Regulation (6) Continuing Competence (7) Professional Responsibility and Accountability (8) Professional Leadership (College of Licensed Practical Nurses of Manitoba, 2004)

120 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements Ontario (College of Nurses of Ontario) Nursing Act The practice of nursing is the promotion of health and the Controlled Acts Registered Jurisprudence Entry-to-Practice Competencies for assessment of, the provision of care for and the treatment Practical Nurse Examination Registered Practical Nurses Regulated Health of health conditions by supportive, preventive, therapeutic, Additional detail Professions Act palliative and rehabilitative means in order to attain or regarding limits and 79 entry-level competencies organized in 5 maintain optimal function conditions is provided categories: in Legislation and (1) Professional Practice (College of Nurses of Ontario, 2020c) Regulation: An (2) Legal Practice Introduction to the (3) Ethical Practice Nursing Act, 1991 (4) Foundations of Practice (5) Collaborative Practice (College of Nurses of Ontario, 2020c) (College of Nurses of Ontario, 2019b)

Professional Standards, Revised 2002 7 Standards: (1) Accountability (2) Continuing Competence (3) Ethics (4) Knowledge (5) Knowledge Application (6) Leadership (7) Relationships (College of Nurses of Ontario, 2018b)

Appendix B - Regulated Nursing in Canada: The Landscape in 2021 121 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements Quebec (Ordre des infirmieres et infirmiers auxiliaires du Quebec) Nurses Act ‘The nursing assistant provides quality, humane and Reserved and Authorized Licensed Professional Professional Competency Profile for respectful care. He/she is an honest and dedicated health Activities Practical Nurse examination of Licensed Practical Nurses Professional Code professional who, through professional activities set out in (LPN) the Ordre des the Professional Code: infirmières et 9 professional competencies organized in 4 fields: Additional details infirmiers auxiliaires • Contributes to the assessment of the person’s state of du Québec (1) Communication health and the implementation of the care plan; regarding limits and (2) Contribution to the evaluation of a • Provides nursing and medical care and treatment in conditions is provided person’s state of health order to maintain health, restore it, and prevent illness; in the (3) Caregiving • Provides palliative care. Professional Code and (4) Professional Development (Ordre des infirmières et infirmiers auxiliaires du Québec, Nurses Act (Ordre des infirmières et infirmiers auxiliaires 2020) du Québec, 2018)

122 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements New Brunswick (Association of New Brunswick Licensed Practical Nurses) Licensed Practical Scope of Practice: Professional Practice Series - Licensed Jurisprudence Entry-Level Competencies for Licensed Nurses Act, 1977 Practical Nurse module Practical Nurses Licensed practical nurses practice autonomously within a (LPN) An Act to Amend the clinically collaborative relationship with other care providers, 76 entry-level competencies organized in 5 Licensed Practical to provide professional nursing services to individuals of categories: Nurses Act all ages, groups (including families) and communities, in a (1) Professional Practice variety of care settings. Nursing Services is the application of (2) Legal Practice practical nursing knowledge and theory in the: assessment of (3) Ethical Practice clients; collaboration in the development of the nursing plan (4) Foundations of Practice of care; implementation of the nursing plan of care, and; (5) Collaborative Practice evaluation of the clients. (Canadian Council for Practical Nurse Nursing services are provided for the purposes of Regulators & Association of New Brunswick promoting health; preventing illness; providing palliative Licensed Practical Nurses, 2013a) and rehabilitative care, and; assisting clients to achieve an optimal state of health. Standards of Practice for Licensed Practical Nurses in Canada Individuals LPNs and RNs within the collaborative relationship share the accountability to determine the level 4 Standards and intensity of clinical collaboration that is required based (1) Professional Accountability and on: the needs of the client, the individual/professional Responsibility capacity of the nursing professionals involved and the (2) Knowledge-Based Practice available supports in the practice environment. As the (3) Service to the Public and Self-Regulation needs of the client increase in complexity, become less (4) Ethical Practice predictable and have a higher risk for negative outcome, the (Canadian Council for Practical Nurse need for clinical collaboration and consultation increases. Regulators, Association of New Brunswick The employer retains the accountability to have policies, Licensed Practical Nurses, 2013b) resources, procedures in place to support ongoing clinical collaboration between the LPN and RN (Association of New Brunswick Licensed Practical Nurses, 2016) New Brunswick Licensed Practical Nurses Competency Profile

Appendix B - Regulated Nursing in Canada: The Landscape in 2021 123 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements Nova Scotia (Nova Scotia College of Nurses) Nursing Act Guidelines for Licensed Practical Nurses in Nova Scotia - - Licensed Jurisprudence Entry-to-Practice Competencies for Licensed Scope of Practice Practical Nurse Exam Practical Nurses Licensed Practical (LPN) Licensed Practical Nurses practice autonomously within 76 entry-level competencies organized in 5 Nurses Act a collaborative relationship with other care providers, to categories: provide professional nursing services to individuals of all (1) Professional Practice ages, groups (including families) and communities, in a (2) Legal Practice variety of care settings. Nursing Services is the application of (3) Ethical Practice practical nursing knowledge and theory in the: assessment of (4) Foundations of Practice clients; collaboration in the development of the nursing plan (5) Collaborative Practice of care; implementation of the nursing plan of care, and; evaluation of the client. (Canadian Council for Practical Nurse Regulators & Nova Scotia College of Nursing services are provided for the purposes of; Nursing, 2013a) promoting health; preventing illness; providing palliative and rehabilitative care, and; assisting clients to achieve an optimal state of health. Standards of Practice for Licensed Practical Nurses in Canada The practice of practical nursing is based on core nursing knowledge derived from the nursing arts and physical, 4 Standards: biological, and behavioural sciences. It involves the (1) Professional Accountability and provision of nursing services: independently for clients with Responsibility predictable outcomes; in consultation with appropriate (2) Knowledge-Based Practice care providers, for clients whose outcomes are variables, (3) Service to the Public and Self- or; under the guidance or direction of a registered nurse, Regulation medical practitioner or other health-care professional (4) Ethical Practice authorized to provide such guidance or direction for clients (Canadian Council for Practical Nurse with unpredictable outcomes Regulators & Nova Scotia College of (College of Licensed Practical Nurses of Nova Scotia, 2014) Nursing, 2013b)

124 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements Prince Edward Island (College of Licensed Practical Nurses of Prince Edward Island) Regulated Health Practical nursing means the health profession in which a Restricted Activities Licensed - Entry-to-Practice Competencies for Licensed Professions Act person applies particular knowledge, skills and judgement Practical Nurse Practical Nurses in providing practical nursing services to another person, (LPN) Licensed Practical including: 76 entry-level competencies organized in 5 Nurse Regulations Additional detail categories: (i) assessing the person, regarding limits and (1) Professional Practice (ii) collaborating in the development of a nursing care conditions is provided (2) Legal Practice plan, in the Licensed Practical (3) Ethical Practice (iii) implementing a nursing care plan, and Nurse Regulations (4) Foundations of Practice (iv) evaluating the person on an ongoing basis for (5) Collaborative Practice purposes including promoting health, preventing illness, or providing palliative or rehabilitative care. (Canadian Council for Practical Nurse Regulators & College of Licensed Practical (Regulated Health Professions Act, 2019) Nurses of Prince Edward Island, 2013a)

Standards of Practice for Licensed Practical Nurses in Canada 4 Standards: (1) Professional Accountability and Responsibility (2) Knowledge-Based Practice (3) Service to the Public and Self-Regulation (4) Ethical Practice (Canadian Council for Practical Nurse Regulators & College of Licensed Practical Nurses of Prince Edward Island, 2013b)

Appendix B - Regulated Nursing in Canada: The Landscape in 2021 125 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies and Controlled Acts or Registration Standards of Practice Reserved Acts Requirements Newfoundland and Labrador (College of Licensed Practical Nurses of Newfoundland and Labrador) Licensed Practical “Practical nurse” means a person who undertakes or - Licensed - Entry-to-Practice Competencies for Licensed Nurse Act performs duties or services relating to the care of patients Practical Nurse Practical Nurses that is consistent with his or her training as approved by (LPN) Licensed Practical the council, or a person acting under the direction of a 76 entry-level competencies organized in Nurse Regulations registered nurse, a qualified medical practitioner or a five categories: member of a health-care profession approved by the (1) Professional Practice minister, who: (2) Legal Practice (3) Ethical Practice (i) performs procedures or treatments prescribed or (4) Foundations of Practice ordered by a registered nurse, medical practitioner, (5) Collaborative Practice or member of a health-care profession approved by the minister, (Canadian Council for Practical Nurse (ii) undertakes or assists in the care of subacutely ill, Regulators & College of Licensed Practical chronically ill, custodial and convalescent patients, Nurses of Newfoundland & Labrador, 2013a) or Standards of Practice and Code of Ethics for (iii) assists registered nurses in the care of acutely ill Licensed Practical Nurses in Canada patients, 4 Standards: but this definition shall not be construed as being an (1) Professional Accountability and approval of the delegation and direction of nursing functions Responsibility by a person other than a registered nurse, but functions (2) Knowledge-Based Practice which may be performed by qualified medical practitioner (3) Service to the Public and Self-Regulation or a member of a health-care profession approved by the (4) Ethical Practice minister, other than a registered nurse or a licensed practical nurse, may be delegated and directed by a member of that (Canadian Council for Practical Nurse health-care profession (Licensed Practical Nurses Act, 2005) Regulators & College of Licensed Practical Nurses of Newfoundland & Labrador, 2013b)

Competency Profile: Scope of Practice for Licensed Practical Nurses

126 Appendix C. Registered Psychiatric Nurses

Overview of Legislation, Regulation, Scope of Practice, Designations, Additional Registration Requirements, Entry Level Competencies, and Standards of Practice by Province/Territory

Legislation Scope of Practice Restricted Designation Additional Entry Level Competencies and Activities, Registration Standards of Practice Controlled Acts Requirements or Reserved Acts Yukon (Yukon Internationally Educated Health Professions) Health Professions Registered Psychiatric Nurses Regulation (Part 4): - Registered - Registered Psychiatric Nurses working Act Psychiatric in the Yukon follow the Code of Ethics & 25. Scope of practice Nurse (RPN) Standards of Practice of the College of (1) Registrants must practice psychiatric nursing in accordance with the Registered Psychiatric Nurses of Manitoba Registered Psychiatric Practice Standards of the College of Registered Psychiatric Nurses Nurses Regulation of Manitoba and the Competency Profile for the Profession of Registered Psychiatric Nurses in Canada developed by the Registered Standards of Psychiatric Nursing Practice Psychiatric Nurses of Canada regulators, including any update or 5 Standards: The Government of replacement of those documents that may occur from time to time. (2) Notwithstanding subsection (1), the registrar may, on the (1) Therapeutic relationships Yukon’s Professional (2) Competent, evidence-informed Licensing & recommendation of the Registered Psychiatric Nurses Advisory Committee, amend or vary the Practice Standards and the practice Regulatory Affairs (3) Professional responsibility and Branch in the Competency Profile to meet Yukon requirements. (3) A registrant must not practice psychiatric nursing contrary to the accountability Department of (4) Leadership and collaboration in Community Services limitations, conditions, or restrictions, if any, that apply to the Certificate of Registration issued to the registrant. quality psychiatric nursing practice is the regulatory (5) Professional ethical practice authority for (4) Registrants must restrict themselves in performing those activities Registered Psychiatric that they are competent to perform and to those that are appropriate (College of Registered Psychiatric Nurses Nurses in Yukon. to their area of practice and the procedure being performed in of Alberta, British Columbia College accordance with the standards of practice approved by the Registrar. of Nursing Professionals, the College Special endorsements – may include in the Certificate of Registration for a of Registered Psychiatric Nurses of registrant one or more special endorsements that authorize the registrant Manitoba, & Registered Psychiatric Nurses to perform specialized psychiatric nursing procedures if the registrant Association of Saskatchewan, 2019) is eligible for full registration and provides to the registrar proof of (a) successfully completing an educational program of specific theory and practice; and (b) passing the applicable examinations. Independent practice permit – entitles a registered psychiatric nurse to practice in an independent practice setting if the registered psychiatric nurse: (a) applies for the independent practice permit on a form acceptable to the registrar; (b) provides proof of (i) successful completion of a baccalaureate degree or higher psychiatric nursing education and three years of relevant psychiatric nursing experience; or (ii) five years of psychiatric nursing practice including relevant supplemental continuing education; and, (c) provides, when requested by the registrar, the proof of insurance coverage required under subsection (2). (Registered Psychiatric Nurses Regulation, 2009)

Appendix C - Regulated Nursing in Canada: The Landscape in 2021 127 Legislation Scope of Practice Restricted Designation Additional Entry Level Competencies and Activities, Registration Standards of Practice Controlled Acts Requirements or Reserved Acts British Columbia (British Columbia College of Nursing Professionals) Health Professions “psychiatric nursing” means the health profession in which a person Restricted activities Registered Online Learning Requisite Skills and Abilities to Become a Act provides the following services: Psychiatric Module: Registered Psychiatric Nurse in B.C. Nurse (RPN) Introduction 7 categories of requisite skills and abilities: (1) health care for the promotion, maintenance and restoration of to British Additional detail (1) Cognitive Nurses (Registered health, with a focus on psychosocial, mental or emotional health; regarding limits Columbia Registered (2) Communication Psychiatric) and conditions is (3) Interpersonal prevention, treatment and palliation of illness and injury, with Practical Regulation (2) provided in the (4) Behavioural a focus on psychosocial, mental or emotional disorders and Nurses’ Ethical, Scope of Practice (5) Physical conditions and associated or comorbid physiological conditions, Professional for Registered (6) Sensory perceptual primarily by: Psychiatric Nurses: and Legal Health Professions Responsibilities (7) Environmental General Regulation Standards, Limits (i) assessing health status, and Conditions (British Columbia College of Nursing (British Columbia Professionals, n.d) (ii) planning, implementing and evaluating interventions, and College of Nursing Professionals, Registered Psychiatric Nurse Entry-Level Competencies (iii) coordinating health services. 2020e) 7 Competencies: (Nurses (Registered Psychiatric) Regulation, 2018) and (1) Therapeutic relationships and Autonomous therapeutic use of self Scope of Practice (2) Body of knowledge and application and Client-specific (3) Collaborative practice Orders (4) Advocacy (5) Quality care and client safety (British Columbia (6) Health promotion College of Nursing (7) Ethical, professional and legal Professionals, 2018) responsibilities (Registered Nurse Psychiatric Regulators Canada, 2014a) Professional Standards for Psychiatric Nursing 5 Standards: (1) Therapeutic relationships (2) Competent, evidence-informed practice (3) Professional responsibility and accountability (4) Leadership and collaboration in quality psychiatric nursing practice (5) Professional ethical practice (British Columbia College of Nursing Professionals, 2019)

128 Legislation Scope of Practice Restricted Designation Additional Entry Level Competencies and Activities, Registration Standards of Practice Controlled Acts Requirements or Reserved Acts Alberta (College of Registered Psychiatric Nurses of Alberta) Health Professions In their practice, psychiatric nurses apply nursing knowledge and skills Registered Registered - Registered Psychiatric Nurse Entry-Level Act and judgment and do one or more of the following: Psychiatric and Psychiatric Competencies Mental Deficiency Nurse (RPN) (a) work with individuals of all ages, families, groups and communities, Nurses Professional 7 Competencies: (b) assess and help address physical, mental, emotional and spiritual Regulation (1) Therapeutic relationships and Registered health needs, therapeutic use of self Psychiatric and (c) develop diagnoses and plan, implement and evaluate nursing care (2) Body of knowledge and application Mental Deficiency and make referrals, (3) Collaborative practice Nurses Professional Restricted activities (4) Advocacy Regulation (4)teach, counsel and advocate to enhance health and well-being, are outlined in (5) Quality care and client safety the Registered (6) Health promotion (5)co-ordinate, supervise, monitor and evaluate the provision of Psychiatric and health services, (7) Ethical, professional and legal Mental Deficiency responsibilities (6)teach nursing theory and practice, Nurses Professional Regulation (Registered Psychiatric Nurse Regulators (7)(manage, administer and allocate resources related to health of Canada and College of Registered services, (Government of Psychiatric Nurses of Alberta, 2014) Alberta, 2005) (8)engage in research related to health and the practice of nursing, and Code of Ethics & Standards of Psychiatric (d) provide restricted activities authorized by the regulations (Health Nursing Practice Professions Act, 2019) 5 Standards (1) Therapeutic relationships (2) Competent, evidence-informed practice (3) Professional responsibility and accountability (4) Professional ethical practice (Registered Psychiatric Nurses of Canada and College of Registered Psychiatric Nurses of Alberta, 2010)

Appendix C - Regulated Nursing in Canada: The Landscape in 2021 129 Legislation Scope of Practice Restricted Designation Additional Entry Level Competencies and Activities, Registration Standards of Practice Controlled Acts Requirements or Reserved Acts Saskatchewan (Registered Psychiatric Nurses Association of Saskatchewan) The Registered The Registered Psychiatric Nurse Scope of Practice - Registered - Registered Psychiatric Nurse Entry-Level Psychiatric Nurses Psychiatric Competencies Registered Psychiatric Nurses Practice to promote mental health, Act Nurse (RPN) increase capacity and facilitate self-efficacy with individuals, groups, 7 competencies: families, communities, and populations. Through the application of (1) Therapeutic relationships and self-awareness and deliberate consciousness, Registered Psychiatric therapeutic use of self Nurses use the therapeutic milieu to promote positive change in both (2) Body of knowledge and application the physical and mental health of the client. Comprehensive psychiatric (3) Collaborative practice nursing care, through the nursing process, assists the individual to meet (4) Advocacy psychosocial, physiological, and developmental needs, including the (5) Quality care and client safety following: (6) Health promotion (7) Ethical, professional and legal • promoting, maintaining, and restoring the holistic health of diverse responsibilities populations; • teaching and practice; (Registered Psychiatric Nurse Regulators • developing authentic therapeutic relationships through application of Canada & Registered Psychiatric Nurses of effective interpersonal skills; and Association of Saskatchewan, 2014) • coordinating mental health and psycho-social services. Standards of Psychiatric Nursing Practice Registered Psychiatric Nurses have general and psychiatric nursing knowledge, skills, and abilities. They practice in diverse settings 5 Standards: with diverse clients, independently and in collaboration with other (1) Therapeutic relationships disciplines. Registered psychiatric nursing practice includes direct (2) Competent, evidence-informed care, administration, education, consultation and research (Registered practice Psychiatric Nurses Association of Saskatchewan, 2013) (3) Professional responsibility and accountability (4) Leadership and collaboration in quality psychiatric nursing practice (5) Professional ethical practice (College of Registered Psychiatric Nurses of Alberta, British Columbia College of Nursing Professionals, The College of Registered Psychiatric Nurses of Manitoba & Registered Psychiatric Nurses Association of Saskatchewan, 2019)

130 Legislation Scope of Practice Restricted Designation Additional Entry Level Competencies and Activities, Registration Standards of Practice Controlled Acts Requirements or Reserved Acts Manitoba (The College of Registered Psychiatric Nurses of Manitoba) Registered Psychiatric “application of psychiatric nursing knowledge, skill and judgment to As part of the Registered - Becoming a Registered Psychiatric Nurse Nurses Act promote mental health, prevent mental illness, minimize the effects transition to the Psychiatric in Manitoba of mental illness and developmental challenges and assist individuals, Regulated Health Nurse (RPN) Registered Psychiatric families, groups and communities to achieve an optimal state of health. Professions Act, 8 categories of requisite skills and abilities: Nurse Regulation The practice includes education, administration and research related to the College has (1) Cognitive psychiatric nursing.” submitted CRPNM (2) Communication Reserved Acts (3) Interpersonal Regulated Health (Registered Psychiatric Nurses Act, 2001) Request, (4) Behavioural Professions Act (5) Physical the CRPNM’s formal (6) Sensory perceptual CRPNM Reserved Acts Request request as part (7) Environmental of the process to (8) Ethical and legal (does not currently Proposed Registered Psychiatric Nurses Scope of Practice Statement develop regulations include Registered recommended by College of Registered Psychiatric Nurses of Manitoba that would provide (College of Registered Psychiatric Nurses of Psychiatric Nurses) for Regulated Health Professions Act: the authorization Manitoba, 2017) for Registered The practice of registered psychiatric nursing is the application of Registered Psychiatric Nurse Entry-Level Psychiatric Nurses Competencies The Registered registered psychiatric nursing skill, knowledge and judgment, with a to perform specific Psychiatric Nurses focus on mental health, addictions and neurodevelopmental disabilities, reserved acts when (1) Therapeutic relationships and Act remains in place to: they transition to therapeutic use of self until the College (a) assist individuals, families, groups, and communities and regulation under (2) Body of knowledge and application transitions under the populations to achieve, maintain and restore their optimal physical, the Regulated (3) Collaborative practice Regulated Health mental, emotional, social and spiritual health; Health Professions (4) Advocacy Professions Act, date (b) assess, diagnose, plan and provide treatment and interventions and Act (College (5) Quality care and client safety unknown. evaluate their effectiveness and to make referrals; of Registered (6) Health promotion (c) teach, counsel and advocate with, or on behalf of, their clients in Psychiatric Nurses of (7) Ethical, professional and legal order to enhance health and well-being; Manitoba, 2018) responsibilities (d) coordinate, supervise, monitor, deliver and evaluate the provision of (Registered Psychiatric Nurse Regulators of health care and psychosocial services; Canada & College of Registered Psychiatric (e) manage, administer and develop systems related to registered Currently, licensed Nurses of Manitoba, 2014) psychiatric nursing and the provision of health care and practical nurses psychosocial services; are governed by Standards of Psychiatric Nursing Practice (f) teach nursing theory and psychiatric nursing practice; the Registered (g) engage in research related to health and the practice of registered Psychiatric Nurses 5 Standards: psychiatric nursing. Act. (1) Therapeutic relationships (2) Competent, evidence-informed (College of Registered Psychiatric Nurses of Manitoba, 2018) practice (3) Professional responsibility and accountability (4) Leadership and collaboration in quality psychiatric nursing practice (5) Professional ethical practice (College of Registered Psychiatric Nurses of Alberta, British Columbia College of Nursing Professionals, the College of Registerd Psychiatric Nurses of Manitoba, & Registered Psychiatric Nurses Association of Saskatchewan, 2019)

Appendix C - Regulated Nursing in Canada: The Landscape in 2021 131 Appendix D. Registered Nurses

Overview of Legislation, Regulation, Scope of Practice, Designations, Additional Registration Requirements, Entry Level Competencies, and Standards of Practice by Province/Territory

Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements Yukon (Yukon Registered Nurses Association) Registered Nurses Registered Nurses Profession Act: - Registered nurse - Standards of Practice for Registered Nurses Profession Act (RN) “nursing” means the application of professional 4 Standards: nursing knowledge, skills, and judgment for the (1) Accountability and Responsibility purpose of: (2) Knowledge‐Based Practice Registered Nurses (3) Client‐Centred Practice Profession Regulation (a) promoting, maintaining, and restoring health, (4) Professional Relationships and Leadership (b) preventing illness, injury, or disability, (Yukon Registered Nurses Association, 2019) € caring for persons who are sick, injured, disabled, or dying, (d) assisting in pre-natal care, childbirth, and post- natal care, € health teaching and health counselling, (f) coordinating health care, or (g) engaging in administration, teaching, or research to implement a matter referred to in paragraphs (a) to (f). (Registered Nurses Profession Act, 2009)

Registered Nurses Profession Act: A registered nurse is entitled to practice nursing within a scope of practice that is determined by the board to be appropriate for a registered nurse based on the requirements. (Registered Nurses Profession Act, 2009)

132 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements Northwest Territories and Nunavut (Registered Nurses Association of the Northwest Territories and Nunavut) Nursing Profession Section 2 of Northwest Territories Nursing - Registered nurse - Becoming a Registered Nurse in the Northwest Act Profession Act and Nunavut Nursing Act: (RN) Territories and Nunavut: Requisite Skills and Abilities 7 categories of requisite skills and abilities: (1) Cognitive Consolidation of the A registered nurse is entitled to apply nursing (2) Behavioural Nursing Act knowledge, skills and judgment: (3) Communication (a) to promote, maintain and restore health; (4) Interpersonal (5) Physical (b) to prevent and alleviate illness, injury and (6) Sensory perceptual disability; (7) Environmental (c) to assist in prenatal care, childbirth and (Registered Nurses Association of the Northwest postnatal care; Territories and Nunavut, 2012) (d) to care for the terminally ill and the dying; Entry-Level Competencies for the Practice of Registered Nurses (effective September 2020) (e) in the coordination of health-care services; 101 competencies grouped thematically under 9 (f) in administration, supervision, education, headings: consultation, teaching, policy development (1) Clinician and research with respect to any of the (2) Professional matters referred to in paragraphs (a) to (e); (3) Communicator and (4) Collaborator (g) to dispense, compound and package drugs (5) Coordinator where the bylaws so permit. (6) Leader (7) Advocate (Nursing Profession Act, 2010) (8) Educator (9) Scholar (Registered Nurses Association of the Northwest Territories and Nunavut, 2019a) Standards of Practice for Registered Nurses and Nurse Practitioners 4 Standards: (1) Responsibility and Accountability (2) Knowledge-Based Practice (3) Client-Centered Practice (4) Professional Relationships and Leadership (Registered Nurses Association of Northwest Territories and Nunavut, 2019b)

Appendix D - Regulated Nursing in Canada: The Landscape in 2021 133 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements British Columbia (British Columbia College of Nursing Professionals) Health Professions Nurses (Registered) and Nurse Practitioner Restricted activities Registered Nurse Jurisprudence Requisite Skills and Abilities: Becoming a Registered Act Regulation: (RN) module Nurse in British Columbia Seven categories of requisite skills and abilities: Nursing is defined as the health profession in The RN and NP (1) Cognitive which a person provides the following services: Nurses (Registered) Regulation outlines Registered Nurse (2) Behavioural and Nurse several restricted activities with certified (3) Communication Practitioner (a) health care for the promotion, maintenance and for general practice that: practice (RN(C)) (4) Interpersonal Regulation restoration of health; (a) Do not require an (5) Physical (6) Sensory perceptual (b) prevention, treatment and palliation of illness order (b) Do require an order (7) Environmental Health Professions and injury, primarily by (i) assessing health status, General Regulation (ii) planning, implementing and evaluating (Government of British (College of Registered Nurses of British Columbia, interventions, and (iii) coordinating health services; Columbia, 2018) 2015) Entry-Level Competencies for Registered Nurses (c) medical assistance in dying. (Effective December 31, 2020) Outline several additional restricted activities 101 competencies grouped thematically under 9 for certified practice headings: (Nurses (Registered) and Nurse Practitioners registrants, including: (1) Clinician Regulation, 2018) (2) Professional (a) prescribing, (3) Communicator compounding, (4) Collaborator dispensing or (5) Coordinator administering (6) Leader medications (7) Advocate (b) make a diagnosis (8) Educator identifying a disease, (9) Scholar disorder or condition as the cause of the (British Columbia College of Nursing Professionals, signs or symptoms 2020g) of the individual. Professional Standards for Registered Nurses and in accordance Nurse Practitioners with an order or successful 4 Standards: completion of (1) Professional Responsibility and Accountability an approved (2) Knowledge-Based Practice certification (3) Client focused Provision of Service program. (4) Ethical Practice (British Columbia College of Nursing Professionals, 2012) Additional detail regarding limits and conditions is provided in Scope of Practice For Registered Nurses (BCCNP, 2020f).

134 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements Alberta (College and Association of Registered Nurses of Alberta) Health Professions In their practice, registered nurses do one or more Restricted Activities Registered nurse eLearning course Requisite Skills and Abilities for Becoming a Registered Act of the following: (RN) on jurisprudence Nurse in Alberta (a) based on an ethic of caring and the goals Seven categories of requisite skills and abilities: and circumstances of those receiving nursing Additional detail Registered services, registered nurses apply nursing regarding limits and Registered Nurse (1) Cognitive Nurses Profession knowledge, skill and judgment to: conditions is provided - Specialist (2) Behavioural Regulation in Restricted Activities (3) Communication (i) assist individuals, families, groups and Standards (4) Interpersonal Government communities to achieve their optimal (5) Physical Organization Act physical, emotional, mental and spiritual (College and Association (6) Sensory perceptual health and well-being, of Registered Nurses of (7) Environmental Alberta, 2019a). (ii) assess, diagnose and provide treatment (College and Association of Registered Nurses of and interventions and make referrals, Alberta, 2011b) (iii) prevent or treat injury and illness, Entry-Level Competencies for the Practice of Registered Nurses (iv) teach, counsel and advocate to enhance health and well-being, 101 competencies grouped thematically under 9 headings: (v) co-ordinate, supervise, monitor and (1) Clinician evaluate the provision of health services, (2) Professional (vi) teach nursing theory and practice, (3) Communicator (4) Collaborator (vii) manage, administer and allocate (5) Coordinator resources related to health services, and (6) Leader (7) Advocate (viii) engage in research related to health and (8) Educator the practice of nursing, and (9) Scholar (b) provide restricted activities authorized by the (College and Association of Registered Nurses of regulations. Alberta, 2019d) (Health Professions Act, 2019) Practice Standards for Regulated Members 5 Standards: (1) Responsibility and Accountability (2) Knowledge-Based Practice (3) Ethical Practice (4) Service to the Public (5) Self-Regulation (College and Association of Registered Nurses of Alberta, 2013)

Appendix D - Regulated Nursing in Canada: The Landscape in 2021 135 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements Saskatchewan (Saskatchewan Registered Nurses Association) The Registered Subsection 2(k) of The Registered Nurse Act - Registered Nurse - Becoming a Registered Nurse in Saskatchewan: Nurses Act defines the practice of registered nursing as: (RN) Requisite Skills and Abilities Seven categories of requisite skills and abilities: (1) Cognitive The performance or co-ordination of health-care Registered Nurse (2) Behavioural services including but not limited to: with Additional (3) Communication Authorized (4) Interpersonal (i) observing and assessing the health status Practice (5) Physical of clients and planning, implementing and [RN(AAP)] (6) Sensory perceptual evaluating nursing care; and (7) Environmental (ii) the counselling, teaching, supervision, (Saskatchewan Registered Nurses Association, 2019a) administration and research that is required to implement or complement health-care Registered Nurse Entry-Level Competencies services; for the purpose of promoting, 101 competencies grouped thematically under 9 maintaining or restoring health, preventing headings: illness and alleviating suffering where the (1) Clinician performance or co-ordination of those (2) Professional services requires: (3) Communicator (iii) the knowledge, skill or judgment of a person (4) Collaborator who qualifies for registration pursuant to (5) Coordinator section 19 or 20; (6) Leader (iv) specialized knowledge of nursing theory (7) Advocate other than that mentioned in subclause (iii); (8) Educator (v) skill or judgment acquired through nursing (9) Scholar practice other than that mentioned in (Saskatchewan Registered Nurses Association, 2019b) subclause (iii); or Registered Nurse Practice Standards (vi) other knowledge of biological, physical, behavioural, psychological and sociological 5 Standards: sciences that is relevant to the knowledge, (1) Professional Responsibility and Accountability skill or judgment described in subclause (iii), (2) Knowledge-Based Practice (iv) or (v). (3) Ethical Practice (4) Service to the Public (Registered Nurses Act, 1988, 2020) (5) Self-Regulation (Saskatchewan Registered Nurses Association, 2019c) Expanded upon in the document ““Interpretation Standards & Competencies for RN Specialty Practices of the RN Scope of Practice”” (Saskatchewan Professional Responsibility and Accountability Registered Nurses Association, 2015) (1) (2) Knowledge-Based Practice (3) Ethical Practice (4) Service to the Public (5) Self-Regulation (Saskatchewan Registered Nurses Association, 2018a) Standards & Competencies for RN with Additional Authorized Practice 5 Standards: (1) Professional Responsibility and Accountability (2) Knowledge-Based Practice (3) Ethical Practice (4) Service to the Public (5) Self-Regulation (Saskatchewan Registered Nurses Association, 2018b)

136 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements Manitoba (College of Registered Nurses of Manitoba) The Regulated Practice of Registered Nursing Regulation: Reserved Acts Registered nurse - Requisite Skills and Abilities Health Professions (RN) Act Five categories of requisite skills and abilities: (1) Cognitive Practice of The practice of registered nursing is the Details regarding the (2) Behavioural Registered Nursing application of registered nursing skill, knowledge limits and criteria of RN (Authorized (3) Communication Regulation and judgment the reserved acts are Prescriber) (4) Physical provided in the Scope (RN(AP)) (5) Sensory College of Registered (I) to assist individuals, families, groups, of Practice for RNs Nurses of Manitoba communities and populations to achieve, document (College of (College of Registered Nurses of Manitoba, 2018d) General Regulation maintain and restore their optimal physical, Registered Nurses of emotional, mental, spiritual and social Manitoba, 2019a) Entry-Level Competencies (ELCs) for the Practice of health; Registered Nurses (II) to assess, diagnose, plan and provide treatment and interventions and evaluate 101 competencies grouped thematically under 9 their effectiveness and to make referrals; Details regarding the headings: (III) to teach, counsel and advocate on behalf of limits and criteria of the (1) Clinician their clients in order to enhance health and reserved acts for RN(AP)s (2) Professional well-being; are provided in the Scope (3) Communicator (IV) to coordinate, supervise, monitor, deliver of Practice for RN(AP)s (4) Collaborator and evaluate the provision of health care; document. (5) Coordinator (6) Leader (V) to manage, administer and develop systems (College of Registered related to registered nursing and the (7) Advocate Nurses of Manitoba, (8) Educator provision of other health care; 2018c) (VI) to teach registered nursing theory and (9) Scholar practice; and (College of Registered Nurses of Manitoba, 2019b) (VII) to engage in research related to health or the practice of registered nursing. Practice Direction: Practice Expectations for RNs RN(AP) 8 Standards: (1) Professional Practice RN practice forms the foundation for RN(AP) scope (2) Professional Communication of practice. (3) Ethical Practice (4) Client-centered Practice (5) Collaborative care (Practice of Registered Nursing Regulation, 2017) (6) Follow-up to diagnosis and test results (7) Practice environment (8) Client records (College of Registered Nurses of Manitoba, 2018a) Practice Direction: Practice Expectations for RN(AP)s 4 Standards: (1) Use of Specific Knowledge, Skill and Judgment (2) Consultation and Collaboration (3) Prescribing Drugs and Devices (4) Ordering Screening and Diagnostic Tests (College of Registered Nurses of Manitoba, 2019c)

Appendix D - Regulated Nursing in Canada: The Landscape in 2021 137 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements Ontario (College of Nurses of Ontario) Regulated Health Nursing’s Scope of Practice Statement: Controlled Acts Registered Nurse Jurisprudence Requisite Skills and Abilities for Nursing Practice in Professions Act, 1991 (RN) examination Ontario Nursing Act, 1991 Seven categories: The practice of nursing is the promotion of health Details regarding the (1) Cognitive and the assessment of, the provision of, care limits and conditions of (2) Behavioural for, and the treatment of, health conditions by the Controlled Acts is (3) Communication supportive, preventive, therapeutic, palliative and provided in the Regulated (4) Interpersonal rehabilitative means in order to attain or maintain Health Professions (5) Physical optimal function. Act and in Legislation (6) Sensory perceptual and Regulation: An (7) Environmental Introduction to the (Nursing Act, 1991, 2017) Nursing Act, 1991. (College of Nurses of Ontario, 2012) (Regulated Health Professions Act, 1991, 2017; College of Nurses Entry-to-Practice Competencies for Registered Nurses of Ontario, 2020) (Effective September 1, 2020) 101 competencies grouped thematically under 9 headings: (1) Clinician (2) Professional (3) Communicator (4) Collaborator (5) Coordinator (6) Leader (7) Advocate (8) Educator (9) Scholar (College of Nurses of Ontario, 2019c)

Professional Standards, Revised 2002 9 Standards: (1) Accountability (2) Continuing competence (3) Ethics (4) Knowledge (5) Knowledge application (6) Leadership (7) Relationships (8) Therapeutic nurse-client relationships (9) Professional relationships (College of Nurses of Ontario, 2018b)

138 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements Quebec (Ordre des infirmieres et infirmiers du Quebec) Nurses Act Scope of practice of the nursing profession is Reserved Activities Registered Nurse Pass the Identify different standards of practice for school Professional Code defined as follows: the nursing exercise consists (RN) professional health nurses, nurses in community for perinatal care, of evaluating the state of health, determining and Details regarding the entrance exam and nursing in mental health (Ordre des infirmieres et ensuring the implementation of the nursing care limits and conditions of of the Ordre infirmiers du Quebec, 2020). and treatment plan, providing care and treatment the Reserved Acts are des infirmieres nurses and medical personnel with the aim of provided in the Nurses et infirmiers du maintaining and restoring the health of human Act, Professional Code Quebec beings in interaction with their environment and and Le champ d’exercice preventing disease as well as providing palliative et les activites reservees care. des infirmieres et infirmiers 3e edition. (Ordre des infirmieres et infirmiers du Quebec, 2016) (Ordre des infirmieres et infirmiers du Quebec, 2016)

Appendix D - Regulated Nursing in Canada: The Landscape in 2021 139 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements New Brunswick (Nurses Association of New Brunswick) Nurses Act According to the Nurses Act: - Registered Nurse Jurisprudence Becoming a Registered Nurse in New Brunswick: (RN) module Requisite Skills & Abilities “nursing” means the practice of nursing and includes the nursing assessment and treatment Seven categories of requisite skills and abilities: of human responses to actual or potential health (1) Cognitive problems and the nursing supervision thereof. (2) Behavioural (3) Communication (Nurses Act, 2002) (4) Interpersonal (5) Physical (6) Sensory perceptual (7) Environmental (Nursing Association of New Brunswick, 2019a) Entry-Level Competencies (ELCs) for the Practice of Registered Nurses in New Brunswick 101 competencies grouped thematically under 9 headings: (1) Clinician (2) Professional (3) Communicator (4) Collaborator (5) Coordinator (6) Leader (7) Advocate (8) Educator (9) Scholar (Nurses Association of New Brunswick, 2019b) Standards of Practice: Registered Nurses 4 Standards: (1) Responsibility and Accountability (2) Knowledge-Based Practice (3) Client-Centered Practice (4) Professional Relationships and Leadership (Nurses Association of New Brunswick, 2019c)

140 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements Nova Scotia (Nova Scotia College of Nursing) Nursing Act According to the Nursing Act, nursing practice - Registered Nurse Jurisprudence Becoming a Registered Nurse in Nova Scotia: Requisite is deemed as the application of specialized (RN) Exam Skills & Abilities and evidence-based knowledge of nursing theory, health and human sciences, inclusive of Seven categories of requisite skills and abilities: principles of primary health care, in the provision (1) Cognitive of professional services to a broad array of clients (2) Behavioural ranging from stable or predictable to unstable or (3) Communication unpredictable, and includes: (4) Interpersonal (5) Physical • assessing clients to establish their state of (6) Sensory perceptual health and wellness (7) Environmental • identifying the nursing diagnosis based on client assessments and analysis of all relevant (Nova Scotia College of Nursing, 2019a) data / information • developing and implementing the nursing component of a client’s plan of care New Entry-Level Competencies for RNs • coordinating client care in collaboration with other health-care disciplines Effective September 1, 2020: 101 competencies • monitoring and adjusting plans of care based grouped thematically under 9 headings: on client responses (1) Clinician • evaluating a client’s outcomes » such other (2) Professional roles, functions and accountabilities within (3) Communicator the scope of practice of the profession, which (4) Collaborator support client safety and quality care, in order (5) Coordinator to: (6) Leader • promote, maintain or restore health (7) Advocate • prevent illness and disease (8) Educator • manage acute illness (9) Scholar • manage chronic disease • provide palliative care (Nova Scotia College of Nurses, 2020) • provide rehabilitative care • provide guidance and counseling • make referrals to other health- Standards of Practice for Registered Nurses care providers and community resources and also includes research, 5 Standards: education, consultation, management, (1) Responsibility and Accountability administration, regulation, policy or (2) Knowledge-Based Practice system development relevant to the (3) Client-Centered Relationships above. (4) Professional Relationships and Leadership (5) Individual Self-Regulation (Nova Scotia College of Nurses, 2013) (Nova Scotia College of Nurses, 2017)

Appendix D - Regulated Nursing in Canada: The Landscape in 2021 141 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements Prince Edward Island (College of Registered Nurses of Prince Edward Island) Regulated Health The Regulated Health Professions Act states: Reserved Activities Registered Nurse Jurisprudence Entry-Level Competencies for Registered Nurses Professions Act (RN) Exam 101 competencies grouped thematically under 9 Registered Nurses headings: Regulations “nursing” means the health profession in which a Additional details (1) Clinician person applies specialized and evidence-based regarding limits and (2) Professional Reserved Activities knowledge of nursing theory and health and conditions is provided in (3) Communicator Regulation human sciences, skills and judgment in providing the Reserved Activities (4) Collaborator professional services to another person, including: Regulation. (5) Coordinator (i) the promotion, maintenance and restoration (6) Leader of health, and (7) Advocate (ii) the prevention, treatment and palliation of (8) Educator illness and injury, primarily by (A) assessing (9) Scholar health status, (B) planning, implementing and (College of Registered Nurses of Prince Edwards evaluating interventions, and (C) coordinating Island, 2019) health services, and (iii) the research, education, management Standards for Nursing Practice or administrative activities incidental to performing the services referred to in 5 Standards: subclauses (i) and (ii). (1) Unique Body of Knowledge (2) Competent Application of Knowledge (Regulated Health Professions Act, 2019) (3) Responsibility and Accountability (4) Advocacy (5) Continuing Competence (College of Registered Nurses of Prince Edward Island, 2018)

142 Legislation Scope of Practice Restricted Activities, Designation Additional Entry Level Competencies Controlled Acts or Registration and Standards of Practice Reserved Acts Requirements Newfoundland and Labrador (College of Registered Nurses of Newfoundland & Labrador) Registered Nurses The scope of nursing practice is defined as the - Registered Nurse - Requisite Skills and Abilities for Entry-Level Registered Act range of roles, functions, responsibilities, and (RN) Nurse Practice activities which registered nurses are educated and Registered Nurses authorized to perform. The broad scope of nursing Seven categories of requisite skills and abilities: Regulations practice reflects all of the roles and activities (1) Cognitive undertaken by registered nurses to address the (2) Behavioural full range of human experiences and responses to (3) Communication health and illness. This includes health promotion, (4) Interpersonal health protection, health maintenance, health (5) Physical restoration, rehabilitation, and palliation. (6) Sensory perceptual (7) Environmental (Association of Registered Nurses of Newfoundland & Labrador, 2006) (Association of Registered Nurses of Newfoundland and Labrador, 2012) Entry-Level Competencies for the Practice of Registered Nurses 101 competencies grouped thematically under 9 headings: (1) Clinician (2) Professional (3) Communicator (4) Collaborator (5) Coordinator (6) Leader (7) Advocate (8) Educator (9) Scholar (Association of Registered Nurses of Newfoundland and Labrador, 2019) Standards of Practice for Registered Nurses and Nurse Practitioners 4 Standards: (1) Responsibility and Accountability (2) Knowledge-Based Practice (3) Client-Centred Practice (4) Professional Relationships and Leadership (College of Registered Nurses of Newfoundland and Labrador, 2019)

Appendix D - Regulated Nursing in Canada: The Landscape in 2021 143 Appendix E. Nurse Practitioners

Overview of Legislation, Regulation, Scope of Practice, Designations, Additional Registration Requirements, Entry Level Competencies, and Standards of Practice by Province/Territory

Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts Yukon (Yukon Registered Nurses Association) Registered Nurses Section 13.1(2) of the Registered Nurses Profession Act - Nurse Successful completion of Foundations for Nurse Practitioner Profession Act establishes the broad authority for NP practice and reads Practitioner an NP exam Practice in the Yukon as follows: (N.P.) Core competencies derived from Subject to regulations setting out exceptions, conditions the Canadian Nurse Practitioner Registered Nurses or restrictions to be placed on the scope of practice of a Core Competency Framework Profession Regulation nurse practitioner, a nurse practitioner is entitled to: Registered Nurse (Nurse (1) Professional Role, (a) make diagnoses to identify diseases, disorders, or Practitioner) Responsibility and conditions; (Reg. N.P.) Accountability (b) communicate a diagnosis; • Clinical Practice (c) order &/or interpret screening and diagnostic tests; • Collaboration, (d) select, recommend, supply, prescribe, or monitor the Consultation and Referral effectiveness of drugs and treatments; &/or • Research (e) perform other procedures authorized by regulations. • Leadership (2) Health Assessment and (Registered Nurses Profession Act, 2009) Diagnosis • Diagnostic Tests (3) Therapeutic Management Registered Nurses Profession Regulation • Prescribing • Supplying/ Administering • outlines the exceptions, conditions and restrictions to Medication the NP’s scope of practice • Compounding Medication • Identifies two additional acts within the scope of • Minor Surgical, Invasive practice of a nurse practitioner and Other Procedures o admission to and discharge of a patient from a (4) Health Promotion and hospital; and Prevention of Illness and Injury o admission to and discharge of an individual from an institution, facility or program. (Yukon Registered Nurses Association, 2012) (Registered Nurses Profession Regulation, 2012)

144 Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts Northwest Territories and Nunavut (Registered Nurses Association of the Northwest Territories and Nunavut) Nursing Profession In addition to the functions set out in subsection 2(1) of the - Nurse Successfully pass the Entry-Level Competencies for Nurse Act Northwest Territories Nursing Profession Act and Nunavut Practitioner Canadian Nurse Practitioner Practitioners in Canada Consolidation of the Nursing Act for registered nurses, a (NP) Examination: Family/All Ages nurse practitioner is entitled to apply advanced nursing (CNPE: F/AA) or 4 entry-level competency knowledge, skills and judgment: categories: Consolidation of the Family Nurse Practitioner (1) Client Care Nursing Act (a) to make a diagnosis identifying a disease, disorder or Registered Examination offered by the • Client Relationship Building condition; Nurse (Nurse American Nurse Credentialing and Communication (b) to communicate a diagnosis to a patient; Practitioner) Center (ANCC Family) • Assessment (c) to order and interpret screening and diagnostic tests (RN(NP)) • Diagnosis authorized in guidelines approved by the Minister; Successful completion of • Management (d) to select, recommend, supply, prescribe and monitor a course on prescribing • Collaboration, Consultation the effectiveness of drugs authorized in guidelines controlled drugs and and Referral approved by the Minister; and substances • Health Promotion (e) to perform other procedures that are authorized in (2) Quality Improvement and guidelines approved by the Minister. Research (3) Leadership (Consolidation of the Nursing Act, 2004; Nursing (4) Education Profession Act, 2010) • Client, Community and Healthcare Team • Continuing Competence (Registered Nurses Association of the Northwest Territories and Nunavut, 2016) Standards of Practice for Registered Nurses and Nurse Practitioners 4 Standards: (1) Responsibility and Accountability (2) Knowledge-Based Practice (3) Client-Centered Care (4) Professional Relationships and Leadership (Registered Nurses Association of the Northwest Territories and Nunavut, 2019b)

Appendix E - Regulated Nursing in Canada: The Landscape in 2021 145 Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts British Columbia (British Columbia College of Nursing Professionals) Health Professions Health Professions Act: Restricted activities Nurse Successfully complete a Entry-Level Competencies for Nurse Act Practitioner written exam and the OSCE Practitioners in Canada nursing” means the health profession in which a person (NP) (Objective Structured Clinical provides the following services: 4 entry-level competency Additional detail Evaluation) Registered categories: Nurses (Registered) health care for the promotion, maintenance and regarding limits and (a) Nurse Family stream (1) Client Care and Nurse restoration of health; conditions provided in Practitioner • Client Relationship Building Practitioner the Scope of Practice ​Canadian Nurse Practitioner (RN-NP) and Communication Regulation (RN & NP) (b) prevention, treatment and palliation of illness and for Nurse Practitioners. Examination (CNPE) in family, injury, primarily by • Assessment 2005 to present ​ • Diagnosis (British Columbia (i) assessing health status, Three streams: American Nurses • Management Health Professions College of Nursing • Collaboration, Consultation (ii) planning, implementing and evaluating Professionals, 2020h) Nurse Credentialing Centre (ANCC) General Regulation examination in family, 2005 to and Referral interventions, and Practitioner • Health Promotion (Family) (NP(F)) present (iii) coordinating health services; (2) Quality Improvement and Nurse American Academy of Nurse Research (c) medical assistance in dying. Practitioner Practitioners (AANP) in family, (3) Leadership (Adult) (NP(A)) 2005 to present (4) Education (Health Professions Act, 1996). • Client, Community and Nurse Adult stream Healthcare Team Practitioner American Nurses • Continuing Competence (Pediatric) Credentialing Centre (ANCC) (NP(P)) (College of Registered Nurses examination in adult, 2005 to of British Columbia & Canadian January 31, 2014 Council of Registered Nurse American Nurses Regulators, 2017) Credentialing Centre (ANCC) Professional Standards for examination in adult- Registered Nurses and Nurse gerontology primary care, Practitioners 2013 to present 4 Standards: American Academy of (1) Professional Responsibility and Nurse Practitioners (AANP) Accountability examination in adult (2) Knowledge-Based Practice gerontology primary care, (3) Client-Focused Provision of 2013 to present Service American Academy of (4) Ethical Practice Nurse Practitioners (AANP) (British Columbia College of Nursing examination in adult, 2005 to Professionals, 2012) present Pediatric stream American Nurses Credentialing Centre (ANCC) examination in pediatrics, 2005 to January 31, 2014 Pediatric Nursing Certification Board (PNCB) nurse practitioner certification exam, 2005 to present

146 Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts Alberta (College and Association of Registered Nurses of Alberta) Health Professions In addition to the registered nurse scope of practice, the Restricted Activities Nurse Pass any examination Entry-Level Competencies for Nurse Act nurse practitioner scope of practice includes: Practitioner respecting nurse practitioner Practitioners in Canada (NP) practice approved by the • advanced health assessment Council 4 entry-level competency • diagnosis Additional detail Nurse categories: Registered Nurses • ordering and interpreting diagnostic tests regarding the standards Practitioner - (1) Client Care Profession Regulation • prescribing pharmacotherapy and expectations Specialist • Client Relationship • treatment and advanced interventions regarding restricted Complete the Practice Building and • monitoring client outcomes activities provided in the Reflection requirement Communication Government • follow-up care of CARNA’s Continuing • Assessment Restricted Activities 4 Streams: Competence Program Organization Act • consultation and referral as required Standards document. NP (Family/All • Diagnosis Ages) • Management (Health Professions Act, 2019) (College and • Collaboration, Association of NP (Adult) Consultation and Referral Registered Nurses of • Health Promotion Registered Nurses Profession Regulation: Alberta, 2019a) NP (Child) (2) Quality Improvement and NP (Child Research Authorizes nurse practitioners to perform all of the (3) Leadership restricted activities that registered nurses perform and - Neonatal Specialty) (4) Education identifies additional restricted activities that are authorized • Client, Community and specifically as part of the scope of practice of nurse Healthcare Team practitioners. • Continuing Competence (College and Association of Registered Nurses of Alberta, (College and Association of 2017) Registered Nurses of Alberta, 2016)

Practice Standards for Regulated Members 5 Standards: (1) Responsibility and Accountability (2) Knowledge-Based Practice (3) Ethical Practice (4) Service to the Public (5) Self-Regulation (College and Association of Registered Nurses of Alberta, 2013)

Appendix E - Regulated Nursing in Canada: The Landscape in 2021 147 Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts Saskatchewan (Saskatchewan Registered Nurses Association) Registered Nurses “practice of registered nursing” means the performance - Registered Pass an approved NP Registered Nurse (Nurse Act, 1988 or co-ordination of health-care services including but not Nurse Examination (only list the Practitioner) Entry-Level limited to: (i) observing and assessing the health status Practitioner Canadian Nurse Practitioner Competencies of clients and planning, implementing and evaluating (RN(NP)) Exam (CNPE) nursing care; and (ii) the counselling, teaching, supervision, 4 entry-level competency administration and research that is required to implement categories: (1) Client Care or complement health-care services; for the purpose of 4 specialties: Successfully complete CDSA promoting, maintaining or restoring health, preventing • Client Relationship NP - Primary Module of Continuing Building and illness and alleviating suffering where the performance Care Competence Program or co-ordination of those services requires: (iii) the Communication knowledge, skill or judgment of a person who qualifies for NP - Adult • Assessment registration pursuant to section 19 or 20; (iv) specialized • Diagnosis knowledge of nursing theory other than that mentioned NP - Pediatrics • Management • Collaboration, in subclause (iii); (v) skill or judgment acquired through NP - Neonatal nursing practice other than that mentioned in subclause Consultation and Referral (iii); or (vi) other knowledge of biological, physical, • Health Promotion behavioural, psychological and sociological sciences that is (2) Quality Improvement and relevant to the knowledge, skill or judgment described in Research subclause (iii), (iv) or (v) (3) Leadership (4) Education (Registered Nurses Act, 1988, 2020) • Client, Community and Healthcare Team SRNA Bylaws • Continuing Competence In the course of engaging in the practice of registered (Saskatchewan Registered Nurses nursing in the nurse practitioner category in one of Association, 2017a) the four specialties, a registered nurse may, subject to conditions or restrictions imposed on his or her licence, Registered Nurse (Nurse perform the following: Practitioner) Practice Standards • in accordance with the standards and competencies, 6 Standards: diagnose and treat common medical disorders; (1) Professional Responsibility and • in accordance with the standards and competencies, Accountability order, perform, receive and/or interpret reports of (2) Knowledge-Based Practice screening and diagnostic tests in the following areas (3) Ethical Practice (see bylaw) (4) Service to the Public • in accordance with the standards and competencies, (5) Self-Regulation and in accordance with federal legislation, prescribe (6) Therapeutic Management and/or dispense: o (i) drugs listed in schedules I, II and III of (Saskatchewan Registered Nurses The Drug Schedules Regulations, 1997, as Association, 2017b) amended from time to time; o (ii) drugs in the Health Canada Non-Insured Health Benefits list, as amended from time to time; o (iii) drugs and Natural Health Products that may be sold without a prescription; • in accordance with the standards and competencies, perform minor surgical and invasive procedures in the following areas (see bylaw) (Saskatchewan Registered Nurses Association, 2019d)

148 Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts Manitoba (College of Registered Nurses of Manitoba) The Regulated The legal authority for Manitoba RN(NP) scope of practice Reserved Acts Registered Pass an approved NP Entry-Level Competencies Health Professions is found in the College of Registered Nurses General Nurse (Nurse Examination for Registered Nurse (Nurse Act Regulations (regulations) under the RHPA. Practitioner) Practitioners) Adult specialty - Adult- RN practice forms the foundation for RN(NP) scope Additional detail RN(NP)) Gerontology Primary Care 4 entry-level competency of practice. Scope of practice refers to the range of regarding the limits and Nurse Practitioner Exam (The categories: Practice of activities that RN(NP)s are both educated and authorized criteria of Reserved Acts American Academy of Nurse (1) Client Care Registered Nursing to perform. The RN(NP) profession’s scope of practice provided in the Scope Practitioners Certification • Client Relationship Regulation of Practice for RN(NP)s Patient boundaries are broad because RN(NP)s work with a Populations: Board) Building and wide range of client populations in a variety of roles and document. Communication Pediatrics - Pediatric Primary settings. The regulations outline the RN(NP) scope of (College of Registered Family (all ages) • Assessment College of practice using the RHPA’s reserved act model. Care Nurse Practitioner • Diagnosis Nurses of Manitoba, Pediatric Exam (The Pediatric Nursing Registered Nurses 2018e) • Management of Manitoba General An individual RN(NP)’s scope of practice is based on (including Certification Board) • Collaboration, foundational RN and Master’s level RN(NP) education. neonatal) Regulation Primary Health Care - Consultation and Referral Professional experience and continuing education • Health Promotion complement the RN(NP)’s scope of practice. Adult Canadian Nurse Practitioner Examination (2) Quality Improvement and (College of Registered Nurses of Manitoba, 2018e) Research Continuing competency (3) Leadership program (4) Education • Client, Community and Healthcare Team • Continuing Competence (College of Registered Nurses of Manitoba , 2016)

Practice Expectations for RN(NP)s 4 Standards: (1) Use of Knowledge, Skill and Judgment (2) Consultation and Collaboration (3) Prescribing Drugs and Devices (4) Ordering Screening and Diagnostic Tests (College of Registered Nurses of Manitoba, 2018b)

Appendix E - Regulated Nursing in Canada: The Landscape in 2021 149 Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts Ontario (College of Nurses of Ontario) Regulated Health From the Nursing Act, 1991: Controlled acts Nurse Pass an approved NP Entry-to-Practice Competencies for Professions Act, 1991 Practitioner Examination for the specialty Nurse Practitioners The nursing scope of practice statement is: the practice Additional detail (NP) certificate requested Nursing Act, 1991 of nursing is the promotion of health and the assessment regarding the controlled 4 entry-level competency of, the provision of care for and the treatment of health acts provided in the Three specialty Adult specialty - Adult- categories: conditions by supportive, preventive, therapeutic, certificates: Gerontology Primary Care (1) Client Care palliative and rehabilitative means in order to attain or Legislation and NP-Adult Nurse Practitioner Exam (The • Client Relationship maintain optimal function. Regulation: An NP-Paediatrics American Academy of Nurse Building and Introduction to the NP-Primary Practitioners Certification Communication (Nursing Act, 1991, 2017) Nursing Act, 1991 Health Care Board) • Assessment document. (NP-PHC) • Diagnosis NP-Anaesthesia Pediatrics - Pediatric Primary • Management (College of Nurses of Care Nurse Practitioner Ontario, 2020c) - not currently • Collaboration, available Exam (The Pediatric Nursing Consultation and Referral Certification Board) • Health Promotion Primary Health Care - (2) Quality Improvement and Canadian Nurse Practitioner Research Examination (3) Leadership (4) Education Jurisprudence Examination • Client, Community and Healthcare Team • Continuing Competence (College of Nurses of Ontario, 2018c)

Nurse Practitioner Practice Standards 6 Standards: (1) Health Assessment (2) Diagnosis (3) Therapeutic Management (4) Collaboration, Consultation, and Referral (5) Conflict of Interest (6) Discontinuing the NP-client relationship (College of Nurses of Ontario, 2019d)

150 Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts Quebec (Ordre des infirmieres et infirmiers du Quebec) Nurses Act Regulation respecting specialized nurse practitioners Medical activities in NP Master’s degree in nursing and - the nurse’s class of a complementary diploma in A specialized nurse practitioner, that is, a nurse who specialization outlined (IPS – French) medical sciences holds a specialist’s certificate in any of the classes of Regulation in the Regulation Specialized specialization referred to in the Regulation respecting the respecting specialized respecting the classes of specialization of specialized nurse practitioner. nurse specialty classes of nurse practitioners practitioner/ Professional examination of specialized nurse A specialized nurse practitioner may perform the following specialized nurse practitioners practitioner medical activities in the nurse’s class of specialization, Infirmiere under the terms and conditions set out in Chapter III: practicienne specialise (1) prescribe diagnostic examinations; Regulation (2) use diagnostic techniques that are invasive or entail Specialty respecting risks of injury; classes: specialized nurse (3) prescribe medications and other substances; (1) Neonatology practitioners (4) prescribe medical treatments; (2) Adult care (5) use techniques or apply medical treatments that are (3) Pediatric invasive or entail risks of injury. care (4) Primary care (Regulation respecting specialized nurse practitioners, (5) Mental 2018) health

Appendix E - Regulated Nursing in Canada: The Landscape in 2021 151 Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts New Brunswick (Nurses Association of New Brunswick) Nurses Act “practice of a nurse practitioner” means the practice in - Nurse Only Primary Health Care NPs Entry-Level Competencies for Nurse which a nurse practitioner may Practitioner are eligible for registration Practitioners (NP) (a) diagnose or assess a disease, disorder or condition, Primary Health Care - 4 entry-level competency and communicate the diagnosis or assessment to the 1 Stream: Canadian Nurse Practitioner categories: patient, Examination (1) Client Care (b) order and interpret screening and diagnostic tests, Primary Health • Client Relationship approved through the process set out in section 10.3, Care or Family/ Building and (c) select, prescribe and monitor the effectiveness of All Ages Communication drugs approved through the process set out in • Assessment section 10.3, and • Diagnosis (d) order the application of forms of energy approved • Management through the process set out in section 10.3. • Collaboration, (Nurses Act, 2002) Consultation and Referral • Health Promotion (2) Quality Improvement and Research (3) Leadership (4) Education • Client, Community and Healthcare Team • Continuing Competence (Nurses Association of New Brunswick, 2016)

Standards for the Practice of Primary Health Care Nurse Practitioners 4 Standards: (1) Professional Responsibility and Accountability (2) Health Assessment and Diagnosis (3) Therapeutic Management (4) Health Promotion and Prevention of Illness and Injury (Nurses Association of New Brunswick, 2017)

152 Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts Nova Scotia (Nova Scotia College of Nursing) Nursing Act The Nursing Act, NP Standards of Practice, Entry-Level - Nurse Jurisprudence Exam Entry-Level Competencies for Nurse Competencies for Nurse Practitioners and other related Practitioner Practitioners in Canada provincial and federal legislation define NP practice in (NP) Pass a NSCN-approved Nova Scotia. controlled drugs & substances 4 entry-level competency theory course or that this categories: Nurse practitioners have the authority to: curriculum was taught in the (1) Client Care 3 Streams of NP program • Client Relationship • Prescribe all medications for which they have Practice: Building and developed the competencies to prescribed for their Successfully complete NP Family/All Ages Communication client population; including controlled drugs and exam depending on area of • Assessment substances, methadone and other opiate agonist Adult practice: Pediatric • Diagnosis therapy agents and cannabis. NPs do not have the • Management legislated authority to receive or dispense medication • Family/All Ages Exam (CNPE) • Collaboration, samples. Consultation and Referral • Perform invasive and non-invasive procedures • Pediatrics Primary Care NP Exam • Health Promotion required for their client’s care and for which they have (2) Quality Improvement and developed and maintained competence. • Adult/ Gerontology Primary Care NP Exam Research • Order all laboratory tests and diagnostic imaging tests (3) Leadership including x-rays, CT scans, ultrasounds and Magnetic (4) Education Resonance Imaging. NPs use the radiologist’s • Client, Community and interpretation of the findings of these tests for Healthcare Team diagnosis and treatment, as they are not authorized to • Continuing Competence perform or interpret them. • Consult with or refer to health-care providers as (Nova Scotia College of Nursing, required for the management of client’s health care. 2016) • Complete Worker’s Compensation Board (WCB) forms as well as order diagnostic tests and treatments, Nurse Practitioner Standards of prescribe medications and arrange consultations for Practice clients receiving care as part of a WCB claim. 5 Standards: • Discharge clients from hospitals. Responsibility and • Pronounce death, complete a Medical Certificate of (1) Death as long as they have completed the necessary Accountability education and are competent. (2) Leadership and Advocacy Assessment and Diagnosis • Perform capacity assessments under the Adult (3) Capacity and Decision Making Act after completing (4) Client Care Management the mandatory education available through the Public (5) Collaboration, Consultation, Trustees office. and Referral • Complete Disability Tax Credit certificates, (Nova Scotia College of Nursing, Employment Insurance and Canada Pension Plan 2018) disability benefits. • Complete third party insurer claim forms. (Nova Scotia College of Nursing, 2019c)

Appendix E - Regulated Nursing in Canada: The Landscape in 2021 153 Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts Prince Edward Island (College of Registered Nurses of Prince Edward Island) Regulated Health In accordance with the Regulated Health Professions Act, Reserved Activities Nurse Pass an approved NP Entry-Level Competencies for Nurse Professions Act Registered Nurses Regulations, a nurse practitioner in PEI Practitioner Examination or Family/All Practitioners in Canada has the legislated authority to: The Regulated Health (NP) Ages Exam (Canadian Nurse Professions Act (Section Practitioner Exam (CNPE)) 4 entry-level competency • diagnose or assess a disease, disorder or condition, 86) and Restricted categories: Registered Nurses and communicate the diagnosis or assessment to the Activities Regulation (1) Client Care Regulations client; provide details about • Client Relationship • order and interpret screening and diagnostic tests; restricted activities. Pass an approved controlled Building and • select, prescribe and monitor the effectiveness of drugs & substances theory Communication Reserved Activities drugs; and (Government of Prince course or that this curriculum • Assessment Regulation • order the application of forms of energy. Edward Island, 2019) was taught in the NP program • Diagnosis • Management (Registered Nurses Regulations, 2018) • Collaboration, Consultation and Referral • Health Promotion (2) Quality Improvement and Research (3) Leadership (4) Education • Client, Community and Healthcare Team • Continuing Competence (Canadian Council of Registered Nurse Regulators, 2016)

Nurse Practitioner Standards for Practice 5 Standards: (1) Professional Responsibility and Accountability (2) Health Assessment and Diagnosis (3) Therapeutic Management (4) Health Promotion and Prevention of Illness and Injury (5) Consultation, Referral, and Transfer (College of Registered Nurses of Prince Edward Island, 2019b)

154 Legislation Scope of Practice Restricted Activities, Designations Additional Registration Entry Level Competencies and Controlled Acts or Requirements Standards of Practice Reserved Acts Newfoundland and Labrador (College of Registered Nurses of Newfoundland and Labrador) Registered Nurses Scope of Practice for NPs - Nurse Successfully completed an NP Entry-Level Competencies for Nurse Act Practitioner exam approved by council Practitioners in Newfoundland & NPs are registered nurses with additional education (NP) Labrador who demonstrate the competencies to independently Completed a prescribing diagnose, order, and interpret diagnostic tests, prescribe 3 categories: Controlled Drugs and 4 entry-level competency Registered Nurses pharmaceuticals and perform clinical procedures. The Substance (CDSA) course. categories: Regulations NP scope of practice is defined by the activities and • Adult (1) Client Care functions that NPs are education and authorized to • Pediatric • Client Relationship perform in accordance with the Registered Nurses Act, • Family/all Building and Registered Nurse Regulations, the Standards of Practice ages Communication for Registered Nurses and Nurse Practitioners and • Assessment organizational policy. • Diagnosis • Management Registered Nurses Regulation • Collaboration, Authority of Nurse Practitioner: Consultation and Referral • Health Promotion 14.(1) A nurse practitioner may (2) Quality Improvement and Research (a) Order the application of a form of energy (3) Leadership permitted by the standards established by the (4) Education council; • Client, Community and (b) Order laboratory or other tests permitted by the Healthcare Team standards established by the council; and • Continuing Competence (c) Prescribed a drug permitted by the standards established by the council. (Association of Registered Nurses of Newfoundland and Labrador, 2016) (Registered Nurses Regulation, 2013) Standards of Practice for Registered Nurses and Nurse Practitioners RN/NP – 4 Standards: (1) Responsibility and Accountability (2) Knowledge-Based Practice (3) Client-Centered Practice (4) Professional Relationships and Leadership NP – Additional 3 Standards: (5) Collaboration, Consultation, and Referral (6) Assessment and Diagnosis (7) Client Care Management (College of Registered Nurses of Newfoundland and Labrador, 2019)

Appendix E - Regulated Nursing in Canada: The Landscape in 2021 155